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30C-036 BERKSHIRE .INS ' Fax:14135684284 Aug 6 2010 8:11 P.01 AC'ORD,. CERTIFICATE OF LIABILITY INSURANCE j 8/6/20 PRODUCER (413)773 -9913 FAX: (413)774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MasasOne 27g8uxanGe Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 638 Greenfield MA 01302 -0638 INSURERS AFFORDING COVERAGE • NAIC# INSURED • INSURER A COntin211tal Western Pella Products, Inc. INSURER B: ATTN: Jobn Benjamin INSURER 0; _ 155 Main Street INSURED: Greenfield MA 01301 -3258 INSURER E: ;OVERAGES 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. - A(;C;RFGA TE I IMITS SHOWN MAY HAVE BEE1 REQ K',FD BY PAID CLAIMS_ INSR ADD'L I POLICY EFFECTIVE POLICY EXPIRATION I TR INSRIT TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDNY) DATE IMM/DDNYI _ - UNITS GENERALLUIBILITY EACHoCr,)IF9$FNCE 1,000,909 X COMMERCIAL GENERAL lW90.1TY DAMAGE TO RENTED 300,000 pE 1I (E.8 eecurrodce1 $ A I CLARICS 1 X I OCCUR CPA020470113 1/1/2010 1/1/2011 MEDEXP(Anroneaerannl $ 15,000 PERSONAL &ADVWARY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PROnUCTS COMP/OPAGE 5 2,000,000 '—j POLICY 11 JFCT 17 LOC AUTIDMOBILELIABILIIY COMBINED,SINGLE $ 1,000,000 ANY AUTO .... ( accident) A ALL OWNED AUTOS MAA020470213 1/1/2010 1/1/2011 BODILY INJURY (Per Person) 6 X SCHEDULED AUTOS -_ X HIRED AUTOS BODILY INJURY S (Par accident) X NON- O'NNED AUTOS PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ • _ 1 w ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: Aqq S EXCE8$IUMBRELLA LIABILITY EACH OCCURRFNtF $ I OCCUR I CLAIMS MADE AGGREGATE -- S ' $_ DEDUCTIBLE RETENTION $ S _ vwy�� �� S A WORKERS COMPENSATION AND X I A' II 77 MITE O FT ' EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH A9CIb S - 5 0 0, 0 0 0 OFFICERIMEMBSREXCLUDED? WCA020470513 1/1/2010 1/1/2011 E.L DISEASE - EAE'MPLCZYEE$ 500,000 If yes, describe under 500,000 SPECIAL PROVI S below - EL DISEASE -POI ICY I imp S OTHER DESCRIPTION OF OPERATIONS /LOCATI0NSNEHICLESIEXC WINONS ADDED BY ENDORSEMENTISPEC IAL PROVISIONS Ope rat zons usual to the sales Of windows & door$• CERTIFICATE HOLDER CANCELLATION (413)736-3390 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE City of Northampton EXPIRATION DATE THEREOF, THE 18BUIN0 INSURER WILL ENDEAVOR TO MAIL 212 Main Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Northampton, MA 01060 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. , - AUTHOR/ZED REPRESENTATIVE Norma Laforest /SPG ACORD 25 (2001108) IIACORD CORPORATION 1988 1NS025 (0108).068 • Pape 1 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents .® e ft Office of Investigations g y 600 Washington Street Boston, MA 02111 Itew www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information D C1 / Please Print Legibly Name ( Business /Organization/Individual): 1 7 � ce e � 3 r2 C. • Address: J55 / S /ree City /State /Zip: I /✓/fi 0 /.20/ Phone #: /J - 7707. O / Are you an employer? Check the appropriate box: ,) Type of project (required): I. [4 I am a employer with L/ 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. Li New construction 2. ❑ 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.t required.] 5. n 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.E Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. Other /cc'oa 7I/ /ow ) comp. insurance required.] .loo r 5 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: cleilig in G! r Ce / Policy # or Self -ins. Lic. #: G it? Q o 7 U 7Q.� 7 .3 Expiration Date: /- / O Job Site Address: 5 L ZL,c • City/State /Zip: \V(1)(((�GtP,u�G. 0 1402 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 cert under the pai7 and penalties of perjury that the information provided above is true and correct. Signature: ii�.J�. Q� �..— Date: Zi I Phone #: ( ' - �� 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 #: �: +� ��i�� ei ✓ '` 4' r : F f . 4 i 4'4 r Office of Consumer Affairs and usiness Regulation = = , 10 Park Plaza Suite 5170 Boston, ass usetts 02116 , Home Improvement : : `'- ctor registration - __,; : "=� Registration: 142279 1 -� ;.,;;,�,�.�{ �` �'� Type: Private Corporation Expiration: 3/2412012 Tr# 294515 PELLA PRODUCTS, INC. ' _.�. GARY SHERMAN vi \.. , ) 155 MAIN STREET ' •� GREENFIELD, MA 01301 _ , , r - ,' ' Update Address and return card. Mark reason for change. fl Address l Renewal fl Employment f Lost Card DPS -CA1 0 50M- 04/04 - 13101218 Rite €onv»wturiea alAe m - � - �, Office of Consumer Affairs & Business Regulation License or registration valid for individul use only — °�_= HOME lMPR YEMENT CONTRACTOR before the expiration date. If found return to . i Office of Consumer Affairs and Business Regulation �r =LIP g Registratiot ' X42279 10 Par!{ Plaza -suite 5170 Ex irat f2O12 Tr# 294515 „` p `�ny� .i� Boston, MA 02116 Type:- .urpo'cation PELLA PRODUCT . Y=� i l GARY SHERMAIKYr, ' ' 155 MAIN STREET 7 € / �, z / . % � . a► _ ' i 1A.eAr1 A. GREENFIELD, MA 013011 Undersecretary . valii ithor signature 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: January 19, 2009 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. 141 ri f t ti itx i ih k $ iy 155 C: io V . iuwct1 bPir t oile . . .- Is a ,x % brAli air - 'Roo* ' � 's i .:.z;' :::. Tiffr 0440 To Whom It May Concern: i e,ti 2 . G (--4 toe t , as property owner, give permission to our c tractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in my home, located a J /L. 1/ ��7'` Roci // (106 Z . Please accept this letter in place of my signature on the permit application. Thank you, 'bEie ' Mwei , T ` PI - : se Print Name Homeowne Signature at SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: t • �7 Not Applicable t ❑ Name of License Holder :�C1,v W 1 �+_ DR, \`kc �V License Number I'55 t \ a'1 n • Ci,c.L.Qnc;QA6 . DID\ Id W9s 1 \ Addre Expiration D e C�0 C. ( i 53 Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number V 55 t•-A Q i r\ Elos r, ; e d tQ - 01361 3 -� \\ Address Expiration Dat Telephone �� 153 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 buil ding permit. Signed Affidavit Attached Yes El No ❑ 11. - Hone Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement indows Alteration(s) r71 Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [O] Other [t]] Brief Description of Proposed \, Work: UGC \n 5 W tnL1D(,J U S • no .Q.)cl Stin d _e.n►n s . Ko S-tbicurail Alteration of existing bedroom Yes No Adding new bedroom Yes No 3 Attached Narrative Renovating unfinished basement Yes ✓No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following; a. Use of building : One Family `/ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT `` I, 151�j \ ."�" Cl.t r\ � C t r , as Owner of the subject property I I 1 hereby authorize � 2 1 l a T� C 1 nC • to act on my behalf, in all matters relative to work authorized by this building permit application. S-e_C � Sig nQ_cl_ c�, c-+ g1I2110 Signature of Owner Date ?Q_AA a- fl)C\OC—A.- i(1,�• , 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. Sig d under the pains and penalties of perjury. Print Na cto 1 Signature of Owner /Agent Date j . Section 4. ZONING AU 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 DON'T KNOW 0 YES IF YES, date issued: 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 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO 0 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 er 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 0 NO a IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton plptt4s,of Permit: Building Department urbICut/brtvi; way. Permrt 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability - Northampton, MA 01060 Two S ets of Structural Plans ` phone.413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: 11 This section to be completed by office 5 12_ T3U -- \ ?;+5 RC. Map Lot Unit M.Q. 0 10 (2 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: I'Nb\ C - V3CA,unUC q\ 512- Name \ r;�'( e (Print) v- Current Mailing Address:(A e_e_Sl1O_G - ( h 1 Telephone Signature J 2.2 Authorized Agent: �1 ? 1 e-t I, 0. 'Pr() doc - 1S5 ,(X \T ■ SA. �,tt_c2cZ -2 .Q--V� \Gl• Name (Prir�ff" ' Current Mailing Address: d1 a a C (til1 ( X7 Signature ' Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 y' oo • 0° (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) ' (-, C6QD . oO Check Number 3 e'oco This Section For Official Use Only Building Permit Number: I ssu D a Signature: Building Commissioner /Inspector of Buildings Date `MUM'S Mt BP- 2011 -0142 GIs #: COMMONWEALTH OF MASSACHUSETTS . p:B oek 30C 036 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0142 Project # JS- 2011- 000236 Est. Cost: $14800.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sa. ft.): 34586.64 Owner: MOORE WAINWRIGHT JEANE E & ROBERT D WAINWRIGHT Zoning: SR(100)/ Applicant: PELLA PRODUCTS, INC AT: 512 BURTS PIT RD Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:8/19/2010 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 # 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 8/19/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner FROM Berkshire Insw -ehe ar°hp (FRI )AUG 14 2009 14: 32 /ST. 14: 28 /No. 7527319504 P 2 `it: IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/05) Page 2 of 2 1NS025 (0109).08a FROM Erer kslhi re I insult- ante , Gr our. (FRI )AUG 14 2009 14: 32/ST. 14: 29 1No. 75273/9504 P 1 ACORD CERTIFICATE OF LIABILITY INSURANCE I si14/200 n • PRODUCER (413)773-9913 FAX: (413)774-3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MassOne Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 638 Greenfield MA 01302 -0638 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental Western Pella Products, Inc. INSURER B: ATTN: John Benjamin INSURER C: 155 Main Street INSURER D: Greenfield MA 01301 -3258 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ALKYL POLICY EFFECTIVE POLICY EXPIRATION LTR JNSRD TYPE OF INSURANCE POLICY NUMBER GATE (MMIDD/YYI DATE (MMIDD/YY) OMITS GENERAL LIABILITY EACH OCCURRENCE 3 1,000,000 X COMMERCIAL GENERAL LABIUTY PREMISESfE o�cn,noncel $ 300,0.0.0 A CLAIMS MADE El OCCUR CPA020470112 1/1/2009 1/1/2010 MEDEXP(An,oneperson) s 15,460 PERSONAL IS ADV INJURY 3 1,000,000 GENERAL AGGREGATE 3 2,000, 000 G AGGREGATE A LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 X I POLICY n I JECT FILM LQC, AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) 1,000,000 A ALL OWNED AUTOS MAA020470212 1/1/2009 1/1/2010 BODILY INJURY X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE �. (Per accident) GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $ =r.: ANY AUTO OTHERTHAN EA ACC AUTO ONLY: AGG $ - EXCESS /UMBRELLA LIABILITY EACH OCf:IIRRFNCE --- OCCUR OCCUR [1 CLAiMS MADE AGGREGATE $ ' `10L'; $ BOO DEDUCTIBLE 3 ?U Cr RETENTION 3 3 - A WORKERS COMPENSATION AND X I TORY UMRS I 1 ER -n' EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L EACH ACCIDENT S 500, 000 OFFICER /MEMBER EXCLUDED? wCA020470512 1/1/2009 1/1/2010 E.LDISEASE - EA EMPLOYEE$ 500,000 If yes, describe under 500 000 SPECIAL PROVISIONS below E.L.DISEASE - POLICYLIMIT _ $ , , OTHER DESCRIPTION OF OPERATI ONS /LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Operations usual to the sales & installation of doors & windows. CERTIFICATE HOLDER CANCELLATION :,: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SHE' Robert Wainwright EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO PAW_ • 512 Burts Pits Road 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT:, Florence, MA 01062 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TIJF;; INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORED REPRESENTATIVE Robin Sargent /RMS ACORD 25 (2001/08) ® ACORD CORPORATION 1988 1NS025 (0108).080 Pape I of 2 ) The Commonwealth of Massachusetts Department of Industrial Accidents . la ' Office of Investigations ti =will= � 600 Washington Street Boston, MA 02111 ,;•, www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): /41 /9^6 �S /� _ Address: /.5 / %d7irl ,S /V't City /State /Zip!C�r6e- / % /V/�4. ,p /3/// Phone #: '/ /J 770 a/57..? Are you an employer? Check the appropriate box: Type of project (required): 1. [j I am a employer with 7 9 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part- time). * have hired the sub - contractors 2. ❑ 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. ❑ 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 employees. [No workers' 13. ❑ Other 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: Gc-V C/ / i 19 n 5 U r 1 r Cc- CO m(2 n y — Policy # or Self -ins. Imo. #: j a. G Az p ,2 'V 7i9 .' 7a Expiration Date: e/- a/ p?O /O n 1.7 � \ �,J k Job Site Address: \. \`- . A1 ���W� \ R ' 0 ‘ 0 .` L L--4 � City /State /Zip, 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 ce u der the pains and penalties of perjury that the information provided above is true and correct. &nature: 4 4 u / Yi-� / �y1 t G✓ Date: DEC 2 9 2008 Phone #: , 77/ . /- x .30 V 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 #: • • • • • • • • • onee ?.lea Board of Banding Regulations and Standards • • 17° � HOMEIM,OVEIAENC CONTRACTOR T{= ' e istr of 42279 • { • . . 'r�• • • Mit PELLA PR• a •••• " • .MI C,'FiAEI. SALT. a '"A" 455 MAN STREET ' GREENFIELD,7vIA :Administrator - • • • • • • Pella Products, ducts, Inc. • • 155 Main Street Greenfield, MA-01301 • Phone: 413 -772 -0153 • Cell: 41.3- 834 -8799 To: Building Inspector From: David White — Installation Manager • Date: January 19, 2009 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. ? cK -Dtp nosiviir,i r : - ot.pAw:p oosicicttcnSapt k tkxnae • L Ci SIAS • EG -1 :1' t • ? • � ,._Itg #p!!!stsT#df►SW►AR1i1 • drS'►� —d $s�aatipge vowli .iFrLrw.'r - • Cs p4.06 • • • SITE RESPONSIBILITIES Customer: Robert Wainwright Date: /05/2009 Order #: Signature: _ Salesperson: Michael Balthazrr Signature: I. L 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 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 call 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 affect the status of a project from being Substantially Complete. 11 In the event that any products are unable to be installed, the final payment will be recalculated. The cost of 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 no bi •' e til a •proved by Pella Products management Type of Installation: New Construction: (tear out installation) © Completely remove interior and exterior Trim, completely remove existing window frame, install new window in rough opening, re -trim both interior and exterior of window / door. Pocket Install : (sash replacement, existing frame remains) n Remove interior or exterior stops, install new window in existing window frame opening, re -use existing or replace window stops (interior or exterior) Some glass loss will occur. Lead Paint Discloser: #1 n Home was built prior to 1978, Lead Paint discloser has been signed and "Protecting Your Family From Lead in Your Home" brochure has been given to Home Owner #21 Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will Authorized to install Yard Sign on 1st day of installation and remove 7 days afterward�•.v��, © Ensure someone over age 18 is present at all times while Pella employees are in the home. ri D eliver and unload products © n P lace drop cloths in work areas © n R emove & reinstall interior and exterior trim if applicable © n R emove & reinstall existing shutters and awnings by contract I �n i Remove existing product and adjust or modify opening as needed For all service needs, I A I P rovide all equipment necessary to install products please call: k800) 957 © El Cut all wood and other materials outside of home Please make sure you I � �' n Install all products purchased mention that your project I ^ I n Insulate and caulk around products was installed by Pella and reference your order I n R emove stickers and perform initial cleaning of all glass surfaces number I I ri D emonstrate proper operation of products n Confirm that all products are in working order 51 I n R emove drop cloths, vacuum and remove all old products from premises n n F inish (paint or stain) product purchased T - 1 � © Cut -back or tie trees, bushes, shrubs from exterior wall I A A rrange to have alarm system disconnected and reconnected El Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor El Remove and reinstall existing window treatments, wall hangings and air conditioning units. 1 ^ 1 R emove and reposition furniture in work area n © Secure pets in a safe manner n © Remove valuable / breakable items from work area n Pit I Remove snow from area of worksite if necessary • �: e 8.1 Licensed Construction Supervisor:_ Not Applicable ❑ Name of License Holder: � CiI J ` W ► �, V ` t Lq l„Q License Number � 5 t` air\ f �n n e_t rkci 0131b\ . 1 [ Address Date ` Signature Telephone Not Applicable ❑ Company Name Registration Number Address C, 0 Expiration Date Telephone -l\�j> — ` 1 O k5 7 ,,4. &i 'j e =" (o v a 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 d No ❑ + j j X02 . $ 9 i The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature x t rrkim �.i'f ,p`tvS .,� ` z s,{' .2 n 5 l ''' �5 DER e €s ;� t R 5 ; gm e 1 • n '> :.t • New House ❑ Addition ❑ Replacementjdows Alteration(s) ❑ Roofing p Or Doors LL�y77 Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [[] Siding [DI Other [0] Brief D cription of Proposed �., �\ I e � Work: \ CAC . Cl \ S \� 6_A f1 C 9Gt VI 0 0'� \ l�� \J•3‘. ;1 Cl0�c \ ") v T U\ Alteration of existing bedroom J Yes No .) Adding new bedroom Yes A• No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet sr., .? � ;- a sa s.f�'f „I s= �' "' "s ® g .,.. “t•,; a. Use of building : One Family . Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction • i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? ' Yes No . I. Septic Tank City Sewer Private well City water Supply •> °em,c. o.- x ` r.+ Yew ', a x� $ „O `ID )2, ( VV CLL '/OC -\ , as Owner of the subject property hereby authorize ' R Q-- \\ Ci. XlL to act on my behalf, in all matters relative to work authorized � bby ` this building permit application. t``� e-� l 4 C\ _ C� \\\'''k- C) q Signature of Ow Date I, \ \`Ck �Cw C. \'f\ C , 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. Print Name Signature of Owner /Agent Date �T_ , 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 1 1 I I I 1 Frontage 1 1 1 H I Setbacks Front 1 I I I I I Side L:1 1 R: 1 Li I R:1 1 { I I 1 Rear 1 1 1 1 1 I Building Height I I 1 I I I Bldg. Square Footage 1 I I 1 I I I 1 I 1 Open Space Footage p 1 1 1 I % I I I I t area minus bldg & paved I I parking) • # of Parking Spaces 1 1 1 I I I Fill: (volume & Location) I A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO CY DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 0" IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exca tion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. g t ,, `1C PrrRD , ° BP- 2010 -0209 GIS #: COMMONWEALTH OF MASSACHUSETTS ObsailmIc 3 . CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0209 Project # JS- 2010 - 000257 Est. Cost: $14900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 34586.64 Owner: MOORE WAINWRIGHT JEANE E & ROBERT D WAINWRIGHT Zoning: SR(100)/ Applicant: PELLA PRODUCTS, INC AT: 512 BURTS PIT RD Applicant Address: Phone: Insurance: 240 MOHAWK TRAIL (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:8/24/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOOR 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 8/24/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Ammimmarsimmwanwri