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30C-035 PELLA PRODUCTS INC 155 MAIN STREET GREENFIELD, MA 01301 • � O - 11A d� `7 1 6 A-, 1 _ r ' — c .u�.sz AA 0/66 Z_ Subject: Disposal of Debris The purpose of this letter is to certify that all the debris resulting from any project undertaken by Pella Products Inc. in your Town will be transported to a dumpster at our main facility at 155 Main Street, Greenfield, MA. Pella Products Inc.is under contract with Waste Management of Massachusetts for the disposal of the contents of this dumpster. Very Truly Yours, PELLA PRODUCTS INC. John P. Benjamin Accounting Manager To Whom It May Concern: I, JCSEPEq /46L/`/<, as property owner, give permission to our contractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in my home, located at 6L 6oJJ6Nce- F fZo2Eu , 11/1 ss; 0 6, Please accept this letter in place of my signature on the permit application. Thank you, Please Print Name y4� Homeowners Signature Date Customer: Joseph Holik Project Name: Holik Joseph 464 Florence Rd Florence MA Order Number: 739 Quote Number: 3622075 Lead Safe Installation Customer Performance Expectations In order to ensure a proper Lead Safe Installation, it is essential that we have you complete the below tasks prior to your installation: ALL furniture needs to be moved at least 8 feet away from any window or door being replaced -53' ALL personal items, wall hangings, and collectibles must be removed prior to your installation date All blinds and any interior window treatments need to be removed prior to your installation date Any non - movable furniture (for example: pianos, entertainment centers, built in cabinets, etc) must be cleared of items and be surface dusted prior to installation 229 You will be responsible for replacing all furniture and personal items after your installation ❑ Other items: What to Expect the Containment/Work Area to Look Like • In order to ensure your safety, we will be taking measures to minimize dust / debris does not spread beyond our work area. This may include the use of plastic sheeting on the floors and /or walls, caution signs, sealing of heating and cooling air vents, and asking that you turn off your HVAC system during our work. • During your Lead Safe Installation, you may also see your installation professional wearing Personal Protection Equipment. A For your own safety, we are not permitted to allow you inside the work area during the removal of your current product or the installation of your new windows / doors. By signing the form below, I am affirming that I understand all the expectations noted above and that I have agreed to have all items completed prior to my installation commencing. I understand that failure to have these items completed will result in the re- scheduling of my installation and that my installation date will be scheduled for the next available date. / /( Custom S�re Date For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com n.: a A IAInni7 n -4-- -4 n F ,i a n n f +n . . . ' �� 8�K��&� ��������0�� ����x�����������-��°���� Form ' , | -[ his sample Ibrin may Lie used by renovation firms todocument compliance with the | I- ederal ple-Mnovation education end renovation, repair, and painting regulations. . O*cupon|Cw`\rrnation . ) 1-'amphicrt Receipt ! �4 / have received a copy w the load hazard imonranm` pamphlet informing nmo,the � from pmovxum`m�"8yoouopn�onn*1� . inv m*^mog unit. /.oc*vny this pamphlet before the work began. . 0%n-ter-occupant C)p+outAcKnovvleugm,n\ ,, u vv |conmm that I own ei live in this property, that no child under the age ot 13 it ides here t no piegriant v"omannsydowhme.andV`moimp,oportvisoota � child-ocnup�ul»ri|�» • Note: .r.'k ettilci resides in if le primacy re5idence of pnrnaw resideruse cit his or her vuslodiat parents, lega ` guardians, foster parent:1, or inlorrnel caretaker it the child lives and sleeps rwmt of the r ito at he caretaker's rer i:Iei i ce . ; . Nate: A cNk'ncr:meU�c,ili\y is: ^pm1g78oui|ciin0visitod regularly by(hosame clificl, under 8 years pf age, oou\|e.at two diKnren cIr1's whin any vveek, For at leas ' J houu each day, provided that (he visits total a\ least O0 hours annually, _ ' It Box A is checked. check either Box 8 or Box C. but not both. , I er:uost that the renovation firm use the Id-ttf wet K practices requit act byLFAtR*nomtioo.Repu. and Painting Rule; or LI (0) I under .:..,l..and that the tirrn pad the renovation will not ho required to uso the � load-sate work u/achcou required by EPA's Renovation, Repair, Painting enc Painting Rule. • ' k 44 ^ : �omzn^yWOv\ e~nc%opwt Oxotak Rer:vaior's Sell Cett heal ion Option (lor tenant-occupied dwellings only) |.wtn pamphlet pamp was cleliverod hut. a'tenant siCjITOttirc wan not obtainable, you may chock the ppropriete box below. O Declined I certify that | have, made n good faNn effort \ deli the lead h nJ information pamphlet to the rental dwelling unit listed below at. the date and time indicated and that the occupant (=Of:lined to sign the conlirmation of roceipt. I further rerN\ that Ii ave ott a copy ol bite pa t Itie unit with the occupant. Li Unavailable tor signature - I certify that I hays made a good faith effort to deliver !he lend hazard information pamphlet hsam the menial clwellir ig unit listed below arid tha |Ae occupant was unavailable (o 'Age the oonfir/nahw)o| receipt. |kxVa certify that ihave|ehu``opyo|UepaT/ph|riuithoun|tbysl|dinOiiundarUmUoorV/by(0\|n how pmnphloi was kJv). _____ . ` Pxnts| Name o(PamooOertif�ogDe|�e� D ' t",i0oaw*w Person Certifying Lead Pamphlet Delivery UnkA1rmyx Note Regarding As native to delivery in pee,ion, you may 'nail the J ��xxm pamphlet \ouai renovailni. Mailing must he documented by a certiliorte ml na limn the post office. Note: Thi torn is riot eliuctive until At:lril 2010. • i _ Test Kit Documentation Form Page , ofeZ Renovation Address: q.6_ lar e C e— � � • - ---------- - - - - -- Unit# - - - -- State: _44 Zip code: 0106 Test Location # ` Test Kit Used: (Circle only one Test Kit # 1 Test Kit # 2 Test Kit # 3 Description Rf test location: K ii i s _ Result: Is lead present? (Circle only one NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit # 2 Test Kit # 3 Description of test location: _ __ __`___ Result: Is lead present? (Circle only one) YES NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit # 2 Test Kit # 3 Description of test location: _ —__ ____^ Result: Is lead present? (Circle only one) YES NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit # 2 Test Kit # 3 Description of test location: Result: Is lead present? (Circle only one) YES NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit # 2 Test Kit # 3 Description of test location: Result: Is lead present? (Circle only one) YES NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit It 2 Test Kit # 3 Description of test location: Result: Is lead present? (Circle only one) YES NO Presumed Test Location # Test Kit Used: (Circle only one) Test Kit # 1 Test Kit # 2 Test Kit # 3 Description of test location: ___,__— _.__ —__ —_ Result: Is lead present? (Circle only one) YES NO.- Presumed Skill Set #1: Using EPA - Recognized Test Kits 4 of • Test. Kit Documentation Form Page 1 of • Owner Information Name of Owner/Occupant: _Z s Address: _ F. I l`S v` G l/1 C L e - City: Fid re i, C e State: A_(--f- Zip code: Q /06',2.. Contact #: 0.(L3) _c - 3 ) Email: Renovation Information Fill out all of the following information that is available about the Renovation Site, Finn, and Certified Renovator. Renovation Address: ____ _ 5a -W E_ a $ _ A. c• - Unit# City: ________ State: ____ Zip code: Certified Firm Name: _ Pei k_ c�cC a c-f h G --- - Address: _5 C`7 tx / S 4-rae f - -- — _],.. City: °ee-n et. L 4Q_ State: �'t Zip code: 0_1 L – _.. Contact #: 7 Z- c! f 3 Email: I k KO r►t s k�r Q I5'3`f . p I let P s t.• 0 Certified Renovator Name: AA, a yvl L c 160 n., S i r Date Certified: 0 3 / 1 & / Test Kit Information Use the following blanks to identify the test kit or test kits used in testing components. Test Kit #1 Manufacturer: pp b i�� _ Manufacture Date: Model: , Le/1k C- h e G ✓c ,_ Serial #: Expiration Date: Test Kit #2 Manufacturer: Manufacture Date: Model: - ---- - - - -- -- - - - - - -- - -- Serial #: -- Expiration Date: ----._.-----•-----------_—__-- • Test Kit #3 Manufacturer: __ Manufacture Date: __ /__..___ /___ Model: _ _ __— _ Serial #: Expiration Date: —__ ________-- _____.__.._.-__- -_ Skill Set 41: Using EPA - Recognized Test Kits 3 of 4 Customer: Joseph Holik Project Name: Holik Joseph 464 Florence Rd Florence MA Order Number: 739 Quote Number: 3622075 delivery time will be subject to a storage and handling fee of 1% of the net amount of the order ($25.00 minimum charge). The Buyer agrees that the product can be delivered without the Buyer present and agrees to accept the shipping documents as proof of delivery. The Buyer agrees not to hold the Seller responsible for any damage to driveways, sidewalks, trees and overhead wires caused by the Seller's delivery vehicles. The Buyer agrees to examine the product(s) upon delivery and within 7 DAYS OF DELIVERY provide the Seller notice of any discrepancy between the product(s) ordered and the products(s) delivered, including hardware. If the Buyer does not provide notice within 7 days the Buyer accepts the product(s) as is. ❑ Project Checklist has been reviewed . Order Totals '�1�'� Taxable Subtotal $3,119.07 Credit Card Approval Signature Sales Tax @ 6.25% $194.94 Non- taxable Subtotal $1,339.00 -.1 oS &Pr-4 , % -ioz -i K Alia Lci s /`7 Total $4,653.01 Customer Name (Please print) Pella Sales Rep Name (Please print) .L c / //' Deposit Received j� Amount Due $4,653.01 P CustomeNSignat re Phi Sales Rep Signature /4//L 12— Date Date For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at w wd.pella.corn n.;..l....l .... A /A/'V147 n....6 -....1 1-1..4- .{1...4 n...... 0 ..f 4 n Customer: Joseph Holk Project Name: Holik Joseph 464 Florence Rd Florence MA Order Number: 739 Quote Number: 3622075 __ Remove interior or exterior stops, install new window in existing sash opening, re -use existing or replace window stops (interior or exterior). Glass loss will occur. Lead Paint Discloser: • 1. V Home was built prior to 1978, Pre Renovation Form signed and "Protecting Your Family From Lead in Your Home" brochure has been given to the Home Owner. 2. Are there children under the age of 6 or women who are pregnant? Pell ill Owner Will _ Authorize install of Yard Sign on 1st day of installation and remove 7 days afterward Finish (paint or stain) product purchased: Trim will be painted by customer _X_ Ensure someone over age 18 is present at all times while Pella Employees are in the home _X Cut -back or tie trees, bushes, shrubs from exterior wall _X_ Arrange to have alarm system disconnected and reconnected - Pella Products can re -route alarm wires but can not reconnect contacts _X_ Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor - $500 charge for site unprepared on 1 day job X_ Remove and reinstall existing window treatments, wall hangings and air conditioning units - 4 -5 feet in front / 1 foot to side with clear path _X_ Remove and reposition furniture in work area X_ Secure pets in a safe manner X Remove valuable / breakable items from work area _X_ Remove snow from area of worksite if necessary _X_ Deliver and unload products _X_ Place drop cloths in work areas _X_ Remove and reinstall interior and exterior trim if applicable _X_ Remove and reinstall existing shutters and awnings by contract _X_ Remove existing product and adjust or modify opening as needed _X_ Provide all equipment necessary to install products X Cut all wood and other materials outside of home _X_ Install all products purchased _X_ Insulate and caulk around products _X_ Remove stickers and perform initial cleaning of all glass surfaces _X_ Demonstrate proper operation of products _X_ Confirm that all products are in working order _X_ Remove drop cloths, vacuum and remove all old products from premises Signature: 2 ' / G-e..- For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com ri",,,,A , - , AIA1 r ....r..r.,.4 n,.i,.;i,A n c ,..c 4■ Customer: Joseph Holik Project Name: Holik Joseph 464 Florence Rd Florence MA Order Number: 739 Quote Number: 3622075 may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance funds due under the contract, which are in . possession of the owner, shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a dispute, the contractor wishes the dispute to be settled by arbitration, this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A Owner: /4-L Contractor: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. Site Responsibilities 1. 50% Deposit required at time of order. 2. Final payment is to be made to installation team on the morning of the last day of installation. 3. If the customer will not be present at time of install, payment is to be made prior. 4. Checks returned NSF will be assessed a fee of $50.00 to cover fees incurred by Pella. Failure to pay your final bill will result in finance charges of 1 -1/2% per month (18% Annual) and legal fees associated in the collection of owed monies. 5. Due to inclement weather or site conditions, it may be necessary to reschedule. 6. We cannot and will not guarantee specific dates or days of the week for installation. 7. Time given to complete a job is an estimate, extension of time is possible. 8. An install appointment will be confirmed at Verification. A courtesy reminder cal will be placed 1 week prior. 9. Unforeseen rot repair will be quoted on site as additional work via a Change Order. 10. Substantial completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are covered by Warranty and do not affect the status of a project from being Substantially Complete. 11. In the even that any products are unable to be installed, the final payment will be recalculated. The cost of the products not installed will be subtracted from the balance due. A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion. 12, Order is not binding until approved by Pella Products management. 13. Pella will secure all necessary Building Permits. Type of Installation: New Construction: (tear out installation - existing frame is disposed of) _ Remove interior and exterior Trim, remove existing window frame, install new window in rough opening, trim both interior and exterior of window / door. Pocket Install: (sash replacement, existing frame remains) For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com A/A /7/147 r + + n..+.,:1.. n c .4 .1f\ Customer: Joseph Holik Project Name: Holik Joseph 464 Florence Rd Florence MA Order Number: 739 Quote Number: 3622075 Line # Location: Attributes 40 Site Responsibilities Qt y t Customer Notes: HOMEOWNER- FOR YOUR INFORMATION LEGAL CONTRACT REQUIREMENTS FOR HOME IMPROVEMENT CONTRACTORS IS DETAILED BELOW THIS SITE RESPONSIBILITIES FORM IS PART OF YOUR CONTRACT WITH PELLA PRODUCTS INC. 155 MAIN STREET, GREENFIELD, MA 01301 HOME IMPROVEMENT CONTRACTOR REGISTRATION # 142279 EXP. 3 -24 -12 FEDERAL TAX ID #: 04- 2303271 The law requires the following fourteen items to be included in any contract between the homeowner and a registered home improvement contractor in all contracts for home improvement work subject to MGL c 142A 1. The complete agreement between the owner and a clear description of any other documents which are part of the agreement. 2. The full names, federal ID, addresses (not PO box #'s) of the parties, the contractor's registration number, the names(s) of the sales person(s)) involved, if any and the date the contract was executed by the parties 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially complete. 4. A detailed description of the work to be done and the materials to be used. 5. The total amount agreed to be paid for the work to be performed under the contract. 6. A time schedule of payments to be made under the contract and the amount of each payment stated in dollars, including all finance charges, if any. Any deposit required to be paid in advance of the start of the work shall not exceed one -third of the total contract price or the actual cost of any material or equipment of a special order or custom made nature, which must be ordered in 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. 7. All parties must sign the contract. 8. There shall be a clear and conspicuous notice stating; a. That all Home Improvement Contractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place - Room 1301 Boston, MA 02108 617 - 727 -3200 x 25239 b. The contractor's registration number must be on the first page of the contract. c. The homeowners three day cancellation rights under MGL c93s48; NGK c 140D s 10or MGL c255D s 14 as may be applicable. d. All warranties on the owners rights under the provisions of 780 CMRR6 and MGL c 142A e. In ten point bold type or larger, directly above the space provided for the signature, the following statement; DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES f. Whether any lien or security interest is on the residence as a consequence of the contract 9. An enumeration of such other matters upon which the owner and contractor may lawfully agree. 10. Any other provisions otherwise required by the applicable laws of the Commonwealth 11. Permit Notice: Every contract shall contain a clause informing the owner of the following; a. and all necessary construction related permits b. that it shall be the obligation of the contractor to obtain such permits as the owner's agent c. that the owner's who secure their own construction related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella ®website at www.pella.com Proposal - Detailed la , Pella Window and Door Showroom of Greenfie Sales Rep Name: ORourke, Dennis 240 Mohawk Trail Sales Rep Phone: (413) 774 -7231 Greenfield, MA 01301 -3209 Sales Rep E -Mail: dorourke @184.pellapdsn.com Phone: 4137747231 Fax: 4137746348 Sales Rep Fax: 413 - 774 -6348 Customer Information Project/Delivery Address Order Information WellKamp Enterprises Inc Elvin George 23 Cooper Creek Rd Tyringham MA Quote Name: 184 Proline, Brown Ext REVISED 10/14/11 PO Box 413 23 Cooper Creek Rd Order Number: 184K3LD03 GREAT BARRINGTON, MA 01230 Lot # Quote Number: 3020218 Day Phone: (413) 528 -1133 TYRINGHAM, MA 01264 Order Type: Non - Installed Sales Mobile Phone: County: BERKSHIRE Wall Depth: Fax Number: (413) 5410062 Owner Name: Payment Terms: 2% 10th /Net 11th E -Mail: gregg @well- kamp.com George Elvin Tax Code: MASS Contact Name: Owner Phone: Cust Delivery Date: 11/30/2011 Greg Wellenkamp Quoted Date: 8/22/2011 Great Plains #: 53C114040 Contracted Date: 11/2/2011 Booked Date: 11/2/2011 Customer PO #: Customer Notes: UPDATED PER 11 -1 -2011 EMAIL #106 REVISED TO TEMPERED & #204 TO 2953 JOB IS BEING ORDERED WITH 2011 YEAR END REBATE OFFER. A REBATE OF $1000.00 WILL BE PAID TO PURCHASING CUSTOMER UPON JOB DELIVERY PRIOR TO 12/1/11, AND UPON ALL ITEMS BEING PAID FOR IN FULL. UPDATED PER 10/14/11 EMAIL REVISIONS. SEE LINE ITEMS #65, 70, 75, 76, 90, 115 & 150 REVISED 10/13/11: PELLA STANDARD SIZE PROLINE WINDOWS, DESIGNER SERIES CONTEMPORARY SLIDING GLASS DOOR, AND SUPPORT PRODUCTS FIXED WINDOWS. BROWN CLAD EXTERIOR, 1ST FLOOR UNFINISHED INTERIOR, 2ND FLOOR PRE - FINISHED WHITE INTERIOR, ADVANCED LOW E GLASS (SUNDEFENSE ON WINDOW #104), SCREENS, 611/16" JAMBS, FINS. NOTES: 1) 1ST FLOOR WINDOWS /DOORS TO BE UNFINISHED INTERIOR REQUIRING FIELD STAINING BY OTHERS. EXCEPTION; 1ST FL MBR & MBATH PRE - FINISHED WHITE INTERIOR. 2) WINDOWS SUPPLIED WITH UNFINISHED INTERIORS HAVE CHAMPAGNE FINISH HARDWARE AND SCREENS PER 10/13/11 CALL. 3) WINDOWS SUPPLIED PRE - FINISHED WHITE INTERIOR HAVE HARDWARE AND SCREENS IN WHITE. 2) CLAD EXTERIOR COLOR FINALIZED AS BROWN 3) MOTORIZED OPERATORS DELETED AND POLE TO BE USED FOR WINDOW #104. 4) FIXED 36" X 36" WINDOW ADDED ABOVE WINODW #104. 5) WORKBENCH AND KITCHEN WINDOWS CHANGED FROM 2 WIDE TO 3 WIDE COMPOSITES. 6) PELLA ARCHITECT SERIES DOORS DELETED. 7) MBR #120 CHANGED FROM 2 WIDE TO SINGLE UNIT Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 Line # Quote Qty PO Qty Description Item Price Ext'd Price 50 1 0 Pre - Finish Disclaimer List Price: $0.00 Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: $0.00 $0.00 Last Revision Date: Customer Notes: PRE - FINISH DISCLAIMER Stained and paint color samples are produced as accurately as possible: however, actual colors may vary from batch. Because wood is a natural product, each window or door will display its own personality with regards to variation in color, texture and grain pattern. Natural wood variations include distinctive grain patterns or unusual shadings in color. Due to the nature of using natural products, Pella Windows and Doors cannot be responsible for the actual degree of variation that may occur in your purchase. Order Pricing Totals Total List Price $4,458.33 Discountable Amount $5,264.93 Discount @ 0.000% $0.00 Non - Discountable Amount ($806.60) Net Before Payment Discount $4,458.33 Payment Discount Amount $0.00 Net After Payment Discount $4,458.33 Taxable Subtotal $3,114.93 Sales Tax @ 6.25% $194.68 Non - taxable Subtotal $1,343.40 Total (Total Net + Taxes) $4,653.01 Deposit Received $2,326.00 Amount Due $2,327.01 Printed on 4/10/2012 Office Order Copy Page 9 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 New Construction: (tear out installation - existing frame is disposed of) Remove interior and exterior Trim, remove existing window frame, install new window in rough opening, trim both interior and exterior of window / door. Pocket Install: (sash replacement, existing frame remains) Remove interior or exterior stops, install new window in existing sash opening, re -use existing or replace window stops (interior or exterior). Glass loss will occur. Lead Paint Discloser: 1. Home was built prior to 1978, Pre Renovation Form signed and "Protecting Your Family From Lead in Your Home" brochure has been given to the Home Owner. 2. Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will Authorize install of Yard Sign on 1st day of installation and remove 7 days afterward Finish (paint or stain) product purchased: Trim will be painted by customer _X_ Ensure someone over age 18 is present at all times while Pella Employees are in the home _X_ Cut -back or tie trees, bushes, shrubs from exterior wall _X_ Arrange to have alarm system disconnected and reconnected - Pella Products can re -route alarm wires but can not reconnect contacts _X_ Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor - $500 charge for site unprepared on 1 day job _X_ Remove and reinstall existing window treatments, wall hangings and air conditioning units - 4 -5 feet in front / 1 foot to side with clear path _X_ Remove and reposition furniture in work area _X_ Secure pets in a safe manner X Remove valuable / breakable items from work area _X_ Remove snow from area of worksite if necessary _X_ Deliver and unload products _X_ Place drop cloths in work areas _X_ Remove and reinstall interior and exterior trim if applicable _X_ Remove and reinstall existing shutters and awnings by contract _X_ Remove existing product and adjust or modify opening as needed _X_ Provide all equipment necessary to install products _X_ Cut all wood and other materials outside of home _X_ Install all products purchased _X_ Insulate and caulk around products _X_ Remove stickers and perform initial cleaning of all glass surfaces _X_ Demonstrate proper operation of products _X_ Confirm that all products are in working order _X_ Remove drop cloths, vacuum and remove all old products from premises Signature: Printed on 4/10/2012 Office Order Copy Page 8 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES f., Whether any lien or security interest is on the residence as a consequence of the contract 9. An enumeration of such other matters upon which the owner and contractor may lawfully agree. 10. Any other provisions otherwise required by the applicable laws of the Commonwealth 11. Permit Notice: Every contract shall contain a clause informing the owner of the following; a. and all necessary construction related permits b. that it shall be the obligation of the contractor to obtain such permits as the owner's agent c. that the owner's who secure their own construction related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance funds due under the contract, which are in possession of the owner, shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a dispute, the contractor wishes the dispute to be settled by arbitration, this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A Owner: Contractor: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. Site Responsibilities 1. 50% Deposit required at time of order. 2. Final payment is to be made to installation team on the morning of the last day of installation. 3. If the customer will not be present at time of install, payment is to be made prior. 4. Checks returned NSF will be assessed a fee of $50.00 to cover fees incurred by Pella. Failure to pay your final bill will result in finance charges of 1 -1/2% per month (18% Annual) and legal fees associated in the collection of owed monies. 5. Due to inclement weather or site conditions, it may be necessary to reschedule. 6. We cannot and will not guarantee specific dates or days of the week for installation. 7. Time given to complete a job is an estimate, extension of time is possible. 8. An install appointment will be confirmed at Verification. A courtesy reminder cal will be placed 1 week prior. 9. Unforeseen rot repair will be quoted on site as additional work via a Change Order. 10. Substantial completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are covered by Warranty and do not affect the status of a project from being Substantially Complete. 11. In the even that any products are unable to be installed, the final payment will be recalculated. The cost of the products not installed will be subtracted from the balance due. A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion. 12. Order is not binding until approved by Pella Products management. 13. Pella will secure all necessary Building Permits. Type of Installation: Printed on 4/10/2012 Office Order Copy Page 7 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 Line # Quote Qty PO Qty Description Item Price Ext'd Price 45 1 0 Site Responsibilities List Price: $0.00 Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: $0.00 $0.00 Last Revision Date: Customer Notes: HOMEOWNER - FOR YOUR INFORMATION LEGAL CONTRACT REQUIREMENTS FOR HOME IMPROVEMENT CONTRACTORS IS DETAILED BELOW THIS SITE RESPONSIBILITIES FORM IS PART OF YOUR CONTRACT WITH PELLA PRODUCTS INC. 155 MAIN STREET, GREENFIELD, MA 01301 HOME IMPROVEMENT CONTRACTOR REGISTRATION # 142279 EXP. 3 -24 -12 FEDERAL TAX ID #: 04- 2303271 The law requires the following fourteen items to be included in any contract between the homeowner and a registered home improvement contractor in all contracts for home improvement work subject to MGL c 142A 1. The complete agreement between the owner and a clear description of any other documents which are part of the agreement. 2. The full names, federal ID, addresses (not PO box #'s) of the parties, the contractor's registration number, the names(s) of the sales person(s)) involved, if any and the date the contract was executed by the parties 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially complete. 4. A detailed description of the work to be done and the materials to be used. 5. The total amount agreed to be paid for the work to be performed under the contract. 6. A time schedule of payments to be made under the contract and the amount of each payment stated in dollars, including all finance charges, if any. Any deposit required to be paid in advance of the start of the work shall not exceed one -third of the total contract price or the actual cost of any material or equipment of a special order or custom made nature, which must be ordered in 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. 7. All parties must sign the contract. 8. There shall be a clear and conspicuous notice stating; a. That all Home Improvement Contractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place - Room 1301 Boston, MA 02108 617- 727 -3200 x 25239 b. The contractor's registration number must be on the first page of the contract. c. The homeowners three day cancellation rights under MGL c93s48; NGK c 140D s 10or MGL c255D s 14 as may be applicable. d. All warranties on the owners rights under the provisions of 780 CMRR6 and MGL c 142A e. In ten point bold type or larger, directly above the space provided for the signature, the following statement; Printed on 4/10/2012 Office Order Copy Page 6 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 Line # Quote Qty PO Qty Description Item Price Ext'd Price 35 1 0 Order Now Discount: (5 %) $194.00 off Expires: 4/30/12 List Price: ($194.00) Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($194.00) ($194.00) Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 40 1 0 INSTALLATION - INSTALLATION List Price: $35.00 Location: None Assigned Rough Opening: Discount %: 0.00 % Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Branch Catalog Net Price: $35.00 $35.00 Last Revision Date: Customer Notes: Permit Fee Printed on 4/10/2012 Office Order Copy Page 5 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 * * * PF -3 - Cut back sills or stops (Interior) Qty 1 * * * LP -2 - Lead safe practices this opening over 150 UI Qty 1 Outside View Line # Quote Qty PO Qty Description Item Price Ext'd Price 20 4 4 Wood Products Stop Colonial 1, Length: 96, Early List Price: $26.83 Location: None Assigned American Stain Rough Opening: 0.5" X 0.5" 1: -1 -1 Accessory Discount %: 0.00 % Frame Size: -1 X -1 Discount $: $0.00 $0.00 Frame Size: Cr' X 0 General Information: Pine Final Wall Depth: Interior Color / Finish: Early American Stain Interior Frame Perimeter (inches): Wrapping Information: Assembly Type: Pella Assembled Net Price: $26.83 $107.32 Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 25 1 0 National Pella Promotion: (15 %) $277.60 off Expires: List Price: ($277.60) Location: 4/30/12 Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Last Revision Date: Net Price: ($277.60) ($277.60) Line # Quote Qty PO Qty Description Item Price Ext'd Price 30 1 0 Local Pella Promotion: (8 %) $335.00 off Expires: 4/30/12 List Price: ($335.00) Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($335.00) ($335.00) Last Revision Date: Printed on 4/10/2012 Office Order Copy Page 4 of 9 Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 Outside View Line # Quote Qty PO Qty Description Item Price Ext'd Price 10 2 2 Architect, Precision Hung Double Hung, 23.75 X 53, List Price: $1,336.41 1 III Location: None Assigned White # MI Rough Opening: 24.25" X 53.5" 1: Non - Standard Size Double Hung, Equal Split Discount %: 0.00 % I II Frame Size: 23.75" X 53" Frame Size: 23 3/4 X 53 Discount $: $0.00 $0.00 General Information: Style Edition, Clad I III II Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White Interior Color / Finish: Early American Stain Interior Frame Perimeter (inches): 154 Glass: Insulated Low E Advanced Argon Gas Assembly Type: Branch Finished Hardware Options: Standard Lock, Brown, No Sash Lift $1,336.41 $2,672.82 Screen: Full Screen, InView Net Price: $1, Last Revision Date: Grille: RMB, No, 3/4 ", Traditional (2W2H / 2W2H), Early American Stain, White, Shipped In Unit Wrapping Information: Perimeter Length = 154 ", Glazing Pressure = 130. Installation Notes: Exterior Trim: White Aluminum Wrap Customer Notes: Exterior Trim: White Aluminum Wrap * * * PF -7 - Anderson Pressure Fit Replacement Qty 1 Outside View Line # Quote Qty PO Qty Description Item Price Ext'd Price 15 1 1 Architect, Double Hung Fixed, 67.5 X 53, White, 3- 1 1/16" List Price: $2,449.79 Location: None Assigned Rough Opening: 68.25" X 53.75" 1: Non - Standard Size Fixed Double Hung Discount %: 0.00 Frame Size: 67 1/2 X 53 Discount $: $0.00 $0.00 Frame Size: 67.5" X 53" General Information: Standard, Clad, Pine Final Wall Depth: 3- 11/16" Exterior Color / Finish: Standard EnduraClad, White - - Frame Perimeter (inches): Interior Color / Finish: Early American Stain Interior ( ) Sash / Panel: Custom, Standard Rectangle Glass, 3 Assembly Type: Pella Assembled Glass: Insulated Low E Advanced Argon Gas Grille: Net Price: $2,449.79 $2,449.79 Last Revision Date: Wrapping Information: 3- 11/16" Factory Applied, Perimeter Length = 241 ", Glazing Pressure = 55. Installation Notes: Exterior Trim: White Aluminum Wrap Customer Notes: Exterior Trim: White Aluminum Wrap * * * MP -8 - Modified Pocket Installation up to 121 -130 UI Qty 1 wlwrap Printed on 4/10/2012 Office Order Copy Page 3 of 9 Order Verification Notes: PM NOTES TO INSTALL: 1 AS MP CENTER PICTURE UNIT W/ 2 AS PFIT FLANKER IN FRONT OF RANCH STYLE DWELLING. DWELLING IS ON THE CORNER OF A BUSY INTERSECTION. PARK IN DRIVEWAY AROUND BACK HOME. LEAD -SAFE PROJECT. NEW PRODUCT IS REPLACING ANDERSON PRESSURE FIT. EXISTING POCKET DEPTH IS 3 -1/2 ", SO YOU WILL NEED TO CUT BACK SILL AND STOPS ON INTERIOR TO ACCOMIDATE CENTER MP FULL FRAME AT 3- 11/16 ", UNIT CANNOT PROJECT MORE TO THE EXTERIOR BECAUSE OF WRAPPING ISSUES IN LINE WITH THE 3 -1/4" PFITS. 2 DOGS. Sales Rep: Adam L. MEN : 2 FOR DAYS: 1 OV SHED: Friday TOTAL MAN -DAYS REQUESTED: 2 4/6/2012 1:00 PM DR Installation Date : 5/4/2012 DATE TIME OV AGENT Days of Week : Friday Thru Job Desription: 1 AS MP CENTER PICTURE UNIT W/ 2 AS PFIT FLANKERS Flights of Stairs to Climb: 1 Sufficient on -site parking? YES Distance to work site from parking: . 50' Do any openings need to be altered? NO Extra Man Required to Lift: NO Scaffolding required? Step Ladders with Plank # of Sections for Pipe Stagging . Material of existing units: Wood Existing Exterior Trim Style: Wood Subsill (medium) Type and Color of Drip Cap: Existing Interior Trim: 2 -1/2" RANCH Color of Existing Trim: STAINED Will paint lines be missed: NO Exterior painting required: NO Counter weight windows w /pockets? : NO Chair Rail: NO Floor Coverings: Hardwood Cut back flooring ?: NO Tile cutter needed ?: NO Siding Type 1: Brick: Siding Exposure: Siding Type 2: Paneling: NO Brake Metal: NO Brickmould: YES Drywall: YES Wallpaper: NO Plaster: NO Other: Approximate height from the ground to the highest opening: 8' Customer: Joseph Holik Quote Description: 739 Architect Series 413 - 586 -3628 Order Number: 739L3EL031 Printed on 4/10/2012 Office Order Copy Page 2 of 9 Office Order Copy c Serl , WO Branch Number: 73900 Order Number: 739L3EL031 W indow Store Name: Quote Number: 3622075 4/ 2- Quote Description: 739 Architect Series 413 - 586 -3628 Project Name: Holik Joseph 464 Florence Rd Florence MA Customer Information Deliver To Address Order Information Joseph Holik Lot # Sales Rep Name: Lukomski, Adam Cust Delivery Date: 5/4/2012 464 Florence Rd Address: Business Segment: Retail Quoted Date: 4/4/2012 464 Florence Rd Market Segment: Single Family Replacement Contract Date: 4/10/2012 Order Type: Installed Sales Booked Date: FLORENCE, MA 01062 -3614 Effective Discount: 0.000% Earliest LRD: Contact Name: FLORENCE, MA 01062 - 3614 Commission Split: Lukomski, Adam - 100% Day Phone: (413) 5863628 County: HAMPSHIRE Tax Code: MASS Mobile Phone: Owner Name: Tax Exempt #: Fax Number: Joseph Holik Payment Terms: C.O.D. Customer PO #: E -Mail: Great Plains #: 53H5863628 Owner Phone: (413) 5863628 Order Verifier Name: DAVID RUFFNER Order Verification Date: 4/6/2012 Customer Number: 6114490 Delivery Instructions: GPS BRICK RANCH STYLE HOME WITH WHITE WINDOWS AND TRIM, LOCATED ON THE CORNER OF A 4 WAY INTERSECTION, #464 MARKED CLEARLY ON THE MAILBOX AT THE END OF THE DRIVEWAY Installation Notes: GPS BRICK RANCH STYLE HOME WITH WHITE WINDOWS AND TRIM, LOCATED ON THE CORNER OF A 4 WAY INTERSECTION, #464 MARKED CLEARLY ON THE MAILBOX AT THE END OF THE DRIVEWAY A ° R ® ° CERTIFICATE OF LIABILITY INSURANCE x/19/20 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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If 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 to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Robin Sargent NAME: g Berkshire Insurance Group, Inc. PHON .Eek (413) 773 -9913 I No); ( 413)774 -3872 117 Main Street E -MAIL rsar ent @berkshireinsurance rou com AppRESS: g g p' INSURER(S) AFFORDING COVERAGE NAIL # Greenfield MA 01301 INsuRERA:Citizens Insur Company of Amer 31534 INSURED INSURERB:The Hanover Insurance Company 10212 Pella Products, Inc. INSURER C : 155 Main Street INSURER D: INSURER E : Greenfield MA 01301 INSURERF: COVERAGES CERTIFICATE NUMBER:12GL, 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 CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM /DINYYYYI (MM(DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 500,000 A CLAIMS -MADE IX OCCUR ZsN941943300 - 1/1/2012 1/1/2013 MEDEXP(Anyoneperson) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 7 POLICY X PRO T Fir] I LOG $ JFC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 _ ANY AUTO BODILY INJURY (Per person) $ A ALL OWNED SCHEDULED ADN939977000 - 11 1/1/2012 1/1/2013 AUTOS X AUTOS BODILY INJURY (Per accident) $ X X NON -OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS (Per accident) PIP -Basic $ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ OED I RETENTION $ $ WORKERS COMPENSATION ST B AND EMPLOYERS' LIABILITY X I T C1RY L S FR OTH- Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y NIA 1/1/2012 1/1/2013 (Mandatory in NH) WHN939976600 -11 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS) LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Operations usual to the sales & installation of windows & doors. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Northampton Puchalski Municipal Building 212 Main Street AUTHORIZED REPRESENTATIVE Northampton, MA 01060 Robin Sargent /RMS ACORD 25 (2010105) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Phone: 413- 772 -0153 Cell: 413- 834 -8799 To: Building Inspector From: David White — Installation Manager Date: March 19, 2012 SUBJECT: Building Permit Applications & Designees Pella Products Incorporated is in the business of replacing windows and doors for our customers. Our process includes providing a building permit for each and every project. I am a licensed Construction Supervisor. Building permits will be applied for using my CSL #091496 and our HIC, # 142279. Please find a copy of my licenses below. N:,,uchusett. - Delnu of Public �afet■ Bo of Buntline. Be anti .tandard. :' /,{,e trooensoaue.inla{ lelaearu�eai6e!!a Construction Supervisor License - Office of Consumer Affairs & Business Regulation License: CS 91496 •2 I'IHOME IMPROVEMENT CONTRACTOR Registration: 142279 Type: • Expiration: 3/24/2014 Supplement C DAVID C WHITE PELLA PRODUCTS, INC. 64 CARPENTER ST ORANGE, MA 01364 DAVID WHITE 155 MAIN STREET - Expuauon: 1'31)2013 GREENFIELD, MA 01301 Undersecretary Tr. 8561 Restricted lo: rya 011- Unrestricted License or registration valid for individul use only 1[; - 1 2 Family Homes before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ;Ord Boston, MA 02116 Failure to possess a current edition t the Massachusetts Siete Raddieg Cade is issue for revocation of this license. Cr y.. , j , , c Refer to: WWV1'.Mass.Gsa /DPS Not valid without signature Each installation will be staffed by our installers who are all licensed in accordance with current building codes. Following are copies of their current licenses. Please accept these individuals as my Designees: Willard Brown CSSL100231 Lorne Befit CS101355 Scott Bowdish CSSL100232 Curt Boyle CS78514 Jeff Pollock CSSL100327 Richard Guillemette CS60082 Duane Cortis CS092246 Vinny Cole CS96838 Dave Ruffner CS57308 Dan Rosenthal CS52165 Chris Gamache CS86946 Bill Leger CS89338 Ron Haskell CS82630 Brian Thompson CS67121 If you have any question please contact me using the numbers listed above. -1- The Commonwealth of Massachusetts Department of Industrial Accidents „Iva 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 Legibly C,- Name ( Business /Organization/Individual): - f Address: /o 5 KK e City /State /Zip: 6jfecr)' Id / MI /10/ Phone #: f6 - 77 - oi Are you an employer? Check the appropriate box: Type of project (required): 1. [ 4 I am a employer with . 5 ❑ I am a general contractor and I 6. ❑ New construction employees (full and /or part- time).* have hired the sub - contractors 2. C I 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.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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 13. ❑ Other 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. *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 policy and job site information. Insurance Company Name: A tie r a r - _d cvf2 Policy # or Self -ins. Lic. #: ( ' H// � 7C — 0 4 _ Expiration Date: /— �'�/- /,3 Job Site Address: 9� -T prey) Ce / o ' City /State /Zip: i I (' C (AA - 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 pe ' lties of perjur that the i formation provided above is tr and correct. rr Signature: e/}� Date: 'T" ,/, (2 Phone #: -[ /X °7 7 y - 7z3( 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 #: SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Tad . n g I v License Number 1 5 - 5 Ni � e e &e/rAe_g 1 Address Expiration Date C y'x 7 72 - 0i53 Signature Telephone 9, Registered Home Improvement Contractor: Not Applicable ❑ ��1 ro AA) A" i C Ii2Z 79 • Company Name Registration Number Ins �,� � � rpe. �, (() Pte, - P&L K A X I 3 2 - 206/ Address n . (� Expiration Date Q;At n C 1 ) �'JQ Telephone `� � — 77 a 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 he 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding ED] Other [Dl Brief Descriptio of Pr. posed Work: a 0f II / ' . tl . d u ) g -tk '4 4 iM Ilan 1 r / : q'an ' U,9 c ex IS , Alteration of existing bedroom Yes iNo Adding new bedroom Yes No / o� Gnu/ Attached Narrative Renovating unfinished basement Yes \J No ( t � Plans Attached Roll - Sheet a j iC 1 1-4 1 A (.a 6a: if New house and or additio to existing housing, complete the following: a. Use of building : One Family v 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 , JO S� P14 1 — /4 a i^I k , as Owner of the subject Property hereby authorize P8 n - I /cc {` roc—` 4- S -T v to act on my behalf, in all matters relative to work authorized by this building permit application. (1 3445 - ag - fr e l, aG ignature of Owner Date I, r On U i j (, iTP , 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. 0 a;t4) C, it) 619 -- "Do Lij 61 I, 4..,t ' re_— Print N U a C� C �,) ilk is. (1-1.3-/ Z Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department 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) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW Q YES Q IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book < Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 of a common plan that will disturb over 1 acre? YES Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. p. r O .rtment u on ly of Northampton S ta t us of Perm j ' t- " ing Department g Curb GutlDrit�eway P ar t ( 1 2 2 Main Street S wertSepticAvallabiiity ZOIZ Room 100 Watet14l1teil Av 1la15tiit N rth mpton, MA 01060 Two Sets O Str urat Mans D e , %' C PT 4 5 7 -1240 Fax 413 - 587 -1272 Piot/Site Plans O ther S pecify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION i f 1.1 Property Address: � L This section to be completed by office - /dfeC ✓ CI Map Lot Unit j 0 r e Ce N O I 06 ZZone Overlay District ) j EIm St. District" CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: r/ OLI � , n Name (Print) Current Mailing A _ �Q� 0106Z. T elephone Signature 2.2 Authorized Agent: I 1 DUI I}A Wh T2_ i,�5 Ma-tf ∎f ree -1 Grem Name (Prin Current Mailing Address: Q 130 0 a C t )fkt ( //S -772 - 0/,C,3 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Li-- 70(), 0O (a) Building Permit Fee QQ 2. Electrical /� l (b) Estimated Total Cost of tJ Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = ( + 2 + 3 + 4 + 5) �f 700.60 Check Number 4147 or `�? C 36 This Section For Official Use Only Building Permit Number: Isate Issued: Signature: Building Commissioner /Inspector of Buildings Date 464 FLORENCE RD BP- 2012 -0920 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30C - 035 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- 2012 -0920 Project # JS- 2012- 001605 Est. Cost: $4700.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 71438.40 Owner: HOLIK JOSEPH L Zoning: SR(100)/ Applicant: PELLA PRODUCTS, INC AT: 464 FLORENCE RD Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:4/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW 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 4/24/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner