17A-236 (5) Window World of Western Massachusetts
HOUSEKEEPING
1029 North Road-Hampton Ponds Plaza,•Westfield MA 01085
Phone(413)485-7335 • Fax(413)-485-7055 NAT-41779-1 BBB
"Simply the Best for Less" www.WindowWorldofSpringfield.com HIC#165641
CSL#57011
Customer.
Phone(h)
Install Address: Phone(w)
Bill Address: E-mail
WINDOW WORLD $245 GLASS OPTIONS ADD UYALUES
4000 Series DH
5" -6000 Series DH(Triple Pane) $27S7 f-L' SolarZone Glass Package- (LE) $79-- ,
1, Picture Window $359 SolarZone Elite Glass Package*(LEE) $89
2 Lite Slider $359 SolarZone TK2 3 Pane Glass/Krypton(6000 Only) $185 1
3 Lite Slider (1/4,112,1/4) (1/3.1/3.1/3) $605 Alf SolarZone packages include 112 screens,Foam Insulation an Jambs and Head Double
Awning $295 — Strength Glass,Double Locks(>29"),Lifetime Glass Breakage and Labor Warranty,Argon Gas
I Casement LH RH $2957777
PRE 1978 BUILT HOMES(FEDERAL LEAD CONTAINMENT LAW)
jwin Casement(Requires 2 Value+)(0973)(0979) $590
Three Lite Casement(Requires 3 Value+) $885 MY HOME WAS BUILT IN THE YEAR,-. INITIAL:�-��
Basement Sliders<55 Ul $250 EPA LEAD SAFE(Per Window) $60 r C
I Hopper(In existing wood)(Vent+$150) $256— EPA LEAD SAFE(Patio DO Bay/Bow/Garden) $100_
Specialty Window - - $ EPA Lead,third party verification: $475.00
_Ba,I Bow(Insulated seat,Int.Casing&Ext Cap) $3375 1 decline third party verification 0(INITIAL):
Garden Window(insulated seat,Int.Casing&Ext.Cap) $1995 —(Initial)I have received a copy of the Lead hazard Fn—formation pamphlet
Grids/EKt.Color/Int.Woodgrain/Cc4ors calculated in WN 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
Roof for Bay/Bow Window $600_ _(initial)I have received a copy of the lead test result(s).
—Second Floor installation $500
Sign: Date:
Window Color `v,
Inside k Outside Name(s)(Print)
WINDOW WORLD UPGRADES MISCELLANEOUS LABOR
Full Screens $45 _Full Exterior White Trim/Wrap(smooTH)pvc) $79_
T, BEIGE Color charge $50--L-Z'-t,-- 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)(FX)(RM)(SM) $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 Removal $30
—Oriel/Cottage Style(40/60)(60/40) $45 Mull to Form Multi-unit $30
Obscure Glass Per Sash(BOT)(FULL) $35/$70
Tempered Glass Per Sash(BOT)(FULL)$601$120 Instal]Interior/Exterior Stops PHITE VINYL)$55
Catalog Options $ Customer Provided Stops/Trim $45
--e
VINYL PATIO DOORS-LH or RH(Outside Looking In) _Install Int rioLCasing $95
(includes.White Interior Casing and Exterior Trim:),, 1�- Repair,'Replace Sill or Brickmould $75
5 Ft/6 Ft:Sliding Patio Door(LH)'(RH) $1500 Mobile I4-o—n�—eCon-v'ers;ion----'-- $200
Ft.Sliding Patio Door(LH)(RH) $1800
I _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.: .$25
! n left If
I Patio Door Grids(Regu (Woodgrain) l;100 Extra labor(Box o
Qr description)$
W JP
oodgrain/Brown(LO)
L '�(CH)JFX) $295 Total Amount Due$-4-
-- - .0J
Exterior Colors $395 50%Deposit Amount:$
Patio Door Triple Pane Upgrade $250
Keyed Lock$36 _ Foot Lock$51 Cash
Storm Door Model Finance-OWells Fargo Other
NO EXTRA WORK IF NOT IN WRITING! [ttrCheCc#ck made to Window World of WM#
�
Exp.Date: V-code
Final-PaymentAmcyunt
To be paid to the installer upon installation.Thank You.
Sales Rep-Recommend ed:-4 Interior Stops TTZxterior Ca In WINDOW WORLD CARES
l;F--LL
Customer Declined: Interior Stop KExterior Capping:_ _St,Jude Children's Research Hospital
WW of W.Massachusetts anticipates starting this work on L4 and being substantially completed in 1 3 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 custammade nature,which must be orderedift 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 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 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
The Commonwealth of Massachusetts
Departntent of Industrial Accidents
Office of Investigations
600 Washington Street
IF� Boston,Af4 02111
H'tb'Yf.ma:ss.gov diu
Workers* Compensation Insurance .Affidavit: Builder: `-
pit icant Information ? -`
Name{Business/Organization•indi%icy : VY 1 FJ Gl) 1" �;c?� QY W�CSTEt2*3 `� �r`�r=e•%'Yt_^ '
Address: 102a NV9-1-4 4Z_Q
City/State/Zip: W 1vs7F i i<U) M lr O t p$S Phone L413 `I S S — 7 33 5'
Are you an employer?Check the appropriate box: Type of project(required):
1.M I am a employer with 2 4. I am a general contractor and I 6 New construction
employees(full 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 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.❑.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.]r c. 152, §1(4),and we have no 13M Other R -AClF,f^VWT
employees. [No workers' W l B vows
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-conttUtors 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: L..1 OE-P- ' 1 MO-MAL tN,SuRp"C - -
Policy#or Self-ins.L^ic. 1U c 2— 3 1 S- 3-77 9 L17 -41� Expiration Date: ±E-J-2� ( __
Job Site Address:. /-7 �a U :� _ City/State/Zip: 1�-� l��1� � � �� �C+j C��Z
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 r the pains penalties of perjury that the information provided above is true and correm
Simature:
Phone -i e3 5 - IW;
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. CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#•
SECT ION 8-CONSTRUCTION SERVICES
-3.1 L Not Applicable ❑
Licensed Construction Supervisor
i Name of license Holder:
License Number
-5-7
i2_11 0 L
Address Expiration Date
i-
Signature Telephone
J -�
/9. Registered Home Improvement Contractor. r f Not Applicable ❑
M,� 14flq
Company Name Registration Number
Address f�iration Date
Telephone
L
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L r–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 Afl davit Attached Yes......
No...... ❑
1. - 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*:.ere
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and or faun
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 o'jEmployers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for perso—m-E
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 ':-
Northampton Ordinances,State and Local Zoning,Laws and State of Massachusetts General Laws Annotated_
Homeowner Signature
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
i Existing Proposed Required by Zoning
i This column to be filled in by
Building Department
Lot Size
Frontage ,
Setbacks Front
Side L: R: L: R:
Rear I
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking-) 'e
0 of Parking Spaces
e�
Fill:
(volume&Location)
e°
A. Has a Special Permit/Variance/Finding ever been isslded for/on the site?
NO O DONT KNOW O '/(ES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registj`y of Deeds?
NO O DO/KN YES O
IF YES: enter Book Page and/or Document'B. Does the site contain a broor wetlands? NO O DONT KNOW O YES IF YES, has a permit been ained from the Conservation Commission?
Needs to be obtained ned O , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, typ//e and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES
IF YES, describe size, type and Location:
E_ Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part or a C--r=
that Wil 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 ❑ Replacemenndows Alteration(s) Roofing
f
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[p]
i
Brief Description of Pr o�sed (t r T t�a j�k'(�.���.]
Work: 1 1 u'U f s ( ir ✓f .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -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
lk. 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
}�1 Ck S as Owner of the subject
property �
hereby authorize I J /I I bus r k U
to act on m/y behalf,in all matters relative to work authorized application. �-
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.
Py nt Name
Signature of Owner/Agent Date
w __ ...._- Department use only
F 't ity of Northampton Status of Permit:
uilding Department Curb ut/Diiveway Permit
�1, 212 Main Street Swer/Se ticAvailabilit
Y
c=
Room 100 WafefN tl Availability
No hamnton, MA 01060 Two Sets of Structural Plans
t e-ACI3 87-1240 Fax 413-587-1272 PlotlS to Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH'A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prooerty Address:
This section to be completed by office
"1 Uj II ` Map Lot Unit
1 b I � �} C� Zone Overlay District
1 � U l�J
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing AddLes�s,J + /�
L-1 I
Set' (.OaiTox+ Telephone��
Signature
2.2 Authorized Ag,-e�-nt:j- ouswtj
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by rmit applicant
1. Bui.Jing (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=(1 +2+3+4+5) l5� Check Number
This Section For Official Use Only
Building Permit Number. Date Issued:
Signature:
Building Commissionerllnspector of Buildings Date
i'
77 LAKE ST BP-2016-0693
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-236 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2016-0693
Project# JS-2016-001165
Est. Cost: $9380.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Lot Size(sq. ft.): 11761.20 Owner: MATHERS THOMAS M&KATHLEEN D
Zoning: URB(100)/ Applicant. ROBERT BUSHEY JR
AT: 77 LAKE ST
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.-INSTALL 14 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