11C-017 (3) 1 BERNACHE ST BP-2017-0133
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2017-0133
Project# JS-2017-000216
Est. Cost: $5122.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Lot Size(sq. ft.): 8755.56 Owner: ASHTON JOSEPH D
Zoning: URA(I00)/ Applicant: ROBERT BUSHEY JR
AT: 1 BERNACHE ST
Applicant Address: Phone: Insurance:
1029 NORTH RD (413) 485-7335 () WC
W E ST F I E L D M A 01085 ISSUED ON:8/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 ft 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 8/1/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED E—D Department use only
Ci of Northampton Statusof�5Pcetr�i*.
JUL 2 9 2016 Bui mg Department is t U nna
• 2 Main Street Sew6r/SeylieAvail®liftlty
met nr�auuesc„ Room 100
NORTHAMPTON MA 01060 muton, MA 01060
phone 413-587-1240 Fax 413-587-1272 PbVSNeparts ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Proppeerrty Addre�ss�: This section to be completed by office
beynan s1 Mapt Lot Unit
District
Leeds mm- 61t53 2g e GveHsy
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: n�
Jas`pp?h Ptsk Vn I Iernn WI sr
Name(Print)- Current Maili Add
41 - F f4 ' 1(0_7u
. See LA,circ ct) Telephone
Signature
2.2 Authorized Agent
RRr7(h`Yt^-T t= 3i,SHE,1 Iozq IvCRTN 29 k STFIELD AAA GI fuS
Name(Print) / „ I /) � Current Mailing Address
I c/ //W�r � 413 4'55 33
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offiaal Use Only
completed by permit applicant
1. Bui.ding 13A -el) (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 cal ,i11�A-'�`9t
6. Total=(1=(1 +2+3+4+5) S (a�.-QJ Check Number
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature.Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition 1 Replacernen widows Alteration(s) 1-1 Roofing n
Or Doors
Accessory JBlldg. El Demolition ❑ New Signs [01 Decks [Q Siding[D] Other[CO
/q (��)
/Bnef D-
iWork: '�Al// ' •p• �. /_t/ / l it, / . is • 110 l (±U OJc.
jAlteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Hans Attached Roll -Sheet
Ga.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?
n. Type of construction
i. Is construction within 100 R 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.
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, J
,)LS-(9 I \' ASh' " l ,as Owner of the subject
property (1YY (�p j
hereby authorize oI:> ty 1 /Y)*\s_ \,
to act on my behalf, in all matters relative to work authorized to this building permit/ap ica n.
t,
( SrF Lcf-� 7 /
Signature of Owner Date
I, 0 Fi=rrv1 tBti5 Ht,L 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.
t.' bf E,CT 5156FEq
Hint Name 1
V 9,v1
7/2 7 (L
Signature of /Agent " Gate
SECTION 8-CONSTRUCTION SERVICES
N7 Licensed Construction Supervisor. Not Applicable ❑
ame of License Holder: RD BV-1.2T C O Si4Et/
License Number
'Z
570 Il
12—/ RODSEVc=u AvE
Address Expiration Dare
i PEEDR4 Nff},,,LLS NIY-} Cl03C 1113 {55$/47171-1
Signature Terte L. 12.<
f - ire
19 Registered Home Improvement Contractor. Not Applicable ❑
RD BELT.
BL S4'j 3-12_ 1 SG< ti
Company NameRegisbeti 3Hu bei
Vv in:D i.c%tint_D 6r LV Sir :L IA 1 C
Address Expiration Date
r 1024 ;VCFTki Q1) w2'311-irt-I ,v11 0105, Telephone yyNs;b7335
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
Iin the denial of the issuance of the building permit
Signed Affidavit Attached Yes 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 10835.1.
Definition of nomeowper: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 homeJp 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 Qiapter 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 .(, Cali-TOS?e i7)
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Exiscine Proposed Required by Zoning
This column tobc filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: A L: 12:
Rear I
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
Parking)
#of Parking Spaces
Fill:
(whir=&won)
A. Has a Special Permit/Variance/Finding - er been issued for/on the site?
NO 0 DONT KNOW O YES a
IF YES, date issued:
IF YES: Was the permit recorded a e Registry of Deeds?
NO O DONT -OW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a br... , body of water or wetlands? NO 0 DONT KNOW O YES 0
IF YES, has a permit ..-n or need to be obtained from the Conservation Commission?
Needs to be obtained s. O Obtained 0 , 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 0 NO O
IF YES, describe size, type and Location:
E VOA the construction advity disturb(clearing,grading.excavation.or filling)over acre or is it 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 are DPW is required.
•
The Commonwealth of Massachusetts
� Department of Industrial Accidents
.,
traf/ ` Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): WINL0W hive' h OF WESTFRiJ MA rs4CNNSETTS
Address: t 02a Not if Rip
City/state/Zip: WE6TFIEL4 MM OtOSS Phone#: 413 `f45 - 7335_ _
Are you an employer?Check the appropriate box: Type of project(required):
I.® I am a employer with 11J 4. ❑ I am a general contractor and 1
employees(full and/or pan-time).` have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These subcontractors have 8. 0 Demolition
workingfor me in an aci employees and have workers'
Y capacity. 9. ❑ Building addition
[No workers'comp.insurance comp. insurance.:
required.] 5. 0 We area corporation and its 10.0 Electrical repairs or additions
3.0 J am a homeowner doing all work officers have exercised their 11.0 Phunbingrepairs or additions
myself[No workers'comp. right of exemption per MOL 12❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees [No workers'
13.�Orherp1lieEsla64T
comp.insurance required] WiPVOWS
'My applicant that checks box al must also fill out the section below showing their workers'compensation policy information
Homeowners who submit this affidavit indicating they am 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 slowing the name of the subcontractors and sure wheeler or not those entities have
employees. Ifthe sub-commctors have eunployees,they must provide their coo kers'coop.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
information
Insurance Company Name: LI earn/ MUTUAL INSURANCE
Policy#or Self-ins.Lic.#: Ng' Z-f3 1 S- 377 q q7 -01(0 Expiation Date: 5- D
�] MI I 7-2 .L i��.7
lob Site Address: I be in Ckl 1 Ic \�f' City/State/Zip: Leeds II IDiLJ3
Attach a copy oldie workers'compensation policy declaration page(showing the policy number and expiation 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 SI,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 cen4., the pews andypeddaes ofperjury that the information provided above true and corrin.
Signature: yA /17 `1, Date: '7 Z7
Phone#: t{13 M Q 5 - *733S
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License k
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk A Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
estern
• /) /, q- \ISI' Window World HamptonPonds Plazza,a Westfield MA 0$1085 �= • -
�I//V/0441? (!A Phone(413)485-7335•• Fax(413)315-3714 »4 I J
"Simply the Best for Less" v .WindowWorldofSpringfleld.com HIC#165641 ti
CSL#57011 •
Customer: .J Phone(h) 5 i T
Install Address: - Phone(w)
Bill Address: 5- , :E-mail
WINDOW WORLD GLASS OPTIONS ADD U-VALUES _
4000 Series DH $245 SolarZone Glass Package' (LE) 579 -
6000 Series DH(Triple Pane) $279
Picture Window $359 SolarZone Elite Glass Package(LEE) $89
2 Lite Slider $359 SolarZone TIB 3 Pane Glass/Krypton(6000 Only) $185
3 Lite Slider 0/4.11011n rta.m.ini $619 `NI SolarZone winged include 112 screens,foam lantana'on iambs and*gamble
Awning $295 Strength Glass,Double Ionics(>291,lifetime Glass Breakage analabar weeesir Antes tar
Casement LH RH $295 PRE 1978 BUILT HOMES(FEDERAL LEAD CONTAINMENT LAW)
_Twin Casement(Requires 2 Value+)(09731(09m) $590 MY HOME WAS BUILT IN THE YEAR Cr INITIAL-i# 7 k
Three Lite Casement(Requires 3 Values-) $885 EPA LEAD SAFE(Per Window) ' ger=-_ . - (2'
Basement Sliders<55 UI $280 EPA LEAD SAFE(Pabo Dr/Say/Bow/Garden) SJUU _ . "
•
Hopper(In existing wooer(Vent $250 '
Specialty Window S EPA Lead,third party verification' $475.00
Ray/Bow Bnsidaletseal,Int Casing a&LWp) $3375
_ 4tlecline third party verification 0(INITIAyf �:b
Garden Window pnwlalnE.wal,Ilh cavilgdrA Cap) 51996 t' .(Initial)I have received a copy at the Lead hazard information pamphlet '
infoming me of the poteMal tsk M He lead hazard exposure from renmadan activity to be
Remove
61Ray/Bow
omrsw__ .,s1ing Ray/Bow nar ides,.VWu3300 performed in my dwelling unit,the EPA"Renovate Right'brochure.
•
Reframe&Rehire(stain/paint not Included) $400 '-.linAap I have recebed aeppy of De lead test result(s)
Roof for Bay/Bow Window $600
Second Floor Installation $500 Sign- -5 ADale
Window Color • '' • ti- / " Neme(s)(P • -
nnq -
Iamb Outside
WINDOW WORLD UPGRADES MISCELLANEOUS LABOR
Full Screens $45 _Full Exterior White Trim/Wrap IBMOORd(PVC.$79 , =
BEIGE Color charge $50 Color Other Than White $I0
Ext Color(AT)(AB)(DC)(RK)(FG)(ER)(CO) $165 Specialty Custom Exterior Trim/Wrap $
Woodgrain Interior 30l(D0)1CHI(FX)(RM)(SMI $95Aluminum/Vinyl or Steel Out $50/$150
Contoured/Flat Grids(TOP)(FULL)(ENDS) $49` - Y
Plaine Grids(Single)/(Doubla)iFat)/(Contour)- $69 Mull Removal $30
_Diamond/Brass Grids(TOP)(FULL) _ --$120 Mull to Form Multi-unit $30
Oriel/Cottage Style(40/60)(60/40) - - $45 Install Interior/Exterior Stops
Obscure Glass Per Sash(BOT)(FULL) $35/$70 (WHITE $55