31A-316 (5) PELLA PRODUCTS INC
155 MAIN STREET
GREENFIELD, MA 01301
T (
<S Ctrd Aop
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 lnc.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, J .: , 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
1-(5- 1.3 r Ave- t Ni o - h, , (v14. O( b G a Please
accept this letter in place of my signature on the
permit application.
Thank you,
Please Print N. e
"0746 (
Ho - e • e - 's Signature Date
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
❑ Project Checklist has been reviewed
Customer Name (Please print) Pella Sales Rep Name (Please print) Order Totals
Taxable Subtotal $2,780.14
Customer Signature Pella Sales Rep Signature Sales Tax @ 6.25% $173.76
Non - taxable Subtotal $2,313.07
Total $5,266.97
Date Date Deposit Received $3,000.00
Amount Due $2,266.97
Credit Card Approval Signature
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 11 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Thank You For Purchasing Pella® Products
PELLA WARRANTY:
Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated into and become a part of this contract.
Please see the warranties for complete details, taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture
within the wall system. Neither Pella Corporation nor Pella Products Inc will be bound by any other warranty unless specifically set out in this contract. However, Pella
Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties.
Clear opening (egress) information does not take into consideration the addition of a Rolscreen [or any other accessory] to the product. You should consult your local building code
to ensure your Pella products meet local egress requirements.
Per the manufacturer's limited warranty, unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually, thereafter.
Variations in wood grain, color, texture or natural characteristics are not covered under the limited warranty.
This form constitutes a contract between Buyer and Seller. Prices are subject to change anytime after 30 days following date of estimate and does not guarantee availability of any product
listed. Pella Products Inc. management has final authority on acceptance of this order. Your signature confirms the accuracy of the product(s) chosen.
Pella Products assumes no responsibility for accuracy of take offs from drawings or blueprints or that the products listed will be sufficient to complete customer's intended project. The Buyer
agrees that the product(s) listed herein are correct, final and cannot be changed, returned or canceled.
Deposits are partial payment of the contract and are not refundable. The Buyer agrees that if paying by credit card that authorization is granted to the seller to debit the Buyers credit card by
signing this contract. The Buyer agrees that payment discounts do not apply when paying with a credit card. A 1 -1/2% SERVICE CHARGE per month (18% PER ANNUM) will be added to all
outstanding balance past our stated terms, plus lawyer and account fees for collecting outstanding accounts.
The Buyer agrees that the customer delivery date is a realistic estimate of when the product is to be delivered. Items remaining in our warehouse for more than 30 days beyond the agreed to
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.
Refer to Pella Corporate Warranty
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 10 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Signature:
Line # 'Location: Attributes
60 • None Assigned 01 HM0000.3" Pella Installation Tape, 150 ft (1) Item Price Qty ext'd Price
$0.00 1 $0.00
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract- Detailed Page 9 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
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 I 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
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 8 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
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.
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 7 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Line # Location: Attributes
55
Site Responsibilities Item Price Qty Ext'd Price
$0.00 1 $0.00
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
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract- Detailed Page 6 of 11
,er Notes:
For more information
Ext'd Price
1 $35.00
_s, visit the Peila® website at www.peila.com
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Line # Location: Attributes
50 N ne Assigned INSTALLATION - INSTALLATION
Item Price Qty Ext'd Price
$35.00 1 $35.00
Customer Notes: Permit Fee
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 5 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Line # Location: Attributes
35 p' National Pella Promotion: $402.00 off Installation Item Price Qty Ext'd Price
($402.00) 1 ($402.00)
Line # Location: Attributes
40 Local Pella Promotion: $254.00 off Product Item Price Qty Ext'd Price
($254.00) 1 ($254.00)
Line # Location: Attributes
45 Order Now Discount: $146.00 off Product Item Price Qty Ext'd Price
($146.00) 1 ($146.00)
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 4 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
Line # Location: Attributes
25 **lone Assigned Architect, Awning Left, 43.5 X 24, White, 3- 11116" Item Price Qty Ext'd Price
$1,753.85 1 $1,753.85
1: Non-Standard Size Left Awning
" 1 Frame Size: 43 1/2 X 24
General Information: Standard, Clad, Pine
Exterior Color / Finish: Standard EnduraClad, White
530 Interior Color / Finish: Prefinished White Interior
Glass: Insulated Low E Advanced Argon Gas
Viewed From Exterior Hardware Options: Standard Roto Operator, White
Screen: Full Screen, White, InView
Grille: ILT, No, 7/8 ", Traditional (3W2H)
Wrapping Information: Foldout Fins, Factory Applied, 3- 11/16" Factory Applied, Perimeter Length = 135 ", Glazing Pressure = 100.
Final Wall Depth: 3- 11/16"
Rough Opening: 44 - 1/4" X 24 - 3/4"
FF -2 - Full Frame Tear Out Installation up to 70 UI Qty 1
EXTTRIM5 - New exterior trim 5/4 X 3 -1/2 PFJ Qty 1
LP -1 - Lead safe practices this opening under 150 UI Qty 1
EXTSTYLEI - Exterior style - picture framed Qty 1
Line # Location: Attributes
30 Project Volume Discount: $65.00 off Product Item Price Qty Ext'd Price
($65.00) 1 ($65.00)
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 3 of 11
Customer: Jeff Green Project Name: Green Jeff 45 Ward Ave Northampton MA Order Number: 739L3JL081 Quote Number: 4108662
EXTSTYLE3 - Exterior style - cedar faux sill Qty 1
Line # , 'Location: Attributes
15 None Assigned Architect, Casement Left, 21 X 29, White, 3. 11/16" Item Price Qty Ext'd Price
11 OM $1,467.31 1 $1,467.31
� '! 1: Non - Standard Size Left Casement
Frame Size: 21 X 29
El PK # General Information: Standard, Clad, Pine
Exterior Color / Finish: Standard EnduraClad, White
530 Interior Color / Finish: Prefinished White Interior
Glass: Insulated Low E Advanced Argon Gas
Viewed From Exterior Hardware Options: Standard Roto Operator, White
Screen: Full Screen, White, InView
Grille: ILT, No, 7/8", Traditional (1W2H)
Wrapping Information: Foldout Fins, Factory Applied, 3- 11/16" Factory Applied, Perimeter Length = 100 ", Glazing Pressure = 170.
Final Wall Depth: 3- 11/16"
Rough Opening: 21 - 3/4" X 29 - 3/4"
EXTTRIM5 - New exterior trim 5/4 X 3 -1/2 PFJ Qty 1
LP -1 - Lead safe practices this opening under 150 UI Qty 1
FF -2 - Full Frame Tear Out Installation up to 70 UI Qty 1
EXTSTYLE3 - Exterior style - cedar faux sill Qty 1
Line # Location: Attributes
20 None Assigned Architect, Casement Right, 21 X 29, White, 3- 11/16" Item Price Qty Ext'd Price
I $1,320.62 1 $1,320.62
al 1: Non - Standard Size Right Casement
i OM Frame Size: 21 X 29
I I PK # General Information: Standard, Clad, Pine
Exterior Color / Finish: Standard EnduraClad, White
530 Interior Color / Finish: Prefinished White Interior
Glass: Insulated Low E Advanced Argon Gas
Viewed From Exterior Hardware Options: Standard Roto Operator, White
Screen: Full Screen, White, InView
Grille: ILT, No, 7/8 ", Traditional (1W2H)
Wrapping Information: Foldout Fins, Factory Applied, 3-11/1T Factory Applied, Perimeter Length = 100 ", Glazing Pressure = 170.
Final Wall Depth: 3- 11/16"
Rough Opening: 21 - 3/4" X 29 - 3/4"
LP -3 - Lead safe opening within an adjacent containment Qty 1
EXTTRIM5 - New exterior trim 5/4 X 3 -1/2 PFJ Qty 1
FF -2 - Full Frame Tear Out Installation up to 70 UI Qty 1
EXTSTYLE3 - Exterior style - cedar faux sill Qty 1
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 2 of 11
Contract - Detailed
?dc Pella Window and Door Showroom of Greenfield Sales Rep Name: Lukomski, Adam
240 Mohawk Trail Sales Rep Phone: (413) 335 -3237
Greenfield, MA 01301 -3209 Sales Rep Fax: 413 - 774 -6348
Phone: 4137747231 Fax: 4137746348 Sales Rep E -Mail: alukomski @184.pellapdsn.com
Customer Information Project/Delivery Address Order Information
Jeff Green Green Jeff 45 Ward Ave Northampton MA Quote Name: 739 Archiect Series 413 -584 -1478
45 Ward Ave 45 Ward Ave
Order Number: 739L3JL081
NORTHAMPTON, MA 01060 Lot # Quote Number: 4108662
Day Phone: (415) 401 -5522 NORTHAMPTON, MA 01060 Order Type: Installed Sales
Mobile Phone: County: HAMPSHIRE Wall Depth:
Fax Number: Owner Name: Payment Terms: C.O.D.
E -Mail: JGREEN @TROUSER.ORG Jeff Green Tax Code: MASS
Contact Name: Owner Phone: (415) 401 -5522 Cust Delivery Date: 10/16/2012
Quoted Date: 9/19/2012
Great Plains #: 53H5841478 Contracted Date: 9/19/2012
Customer Number: 1005228680 Booked Date: 9/19/2012
Customer Account: 1001415637 Customer PO #:
Customer Notes: CUSTOMER REQUESTS THAT SPRAY FOAM INSULATION BE USED AROUND ALL THE WINDOWS.
Line # Location: Attributes
10 None Assigned Architect, Double Hung, 21 X 40, White, 3-11/16" Item Price Qty Ext'd Price
$1,383.43 1 $1,383.43
9 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 21 X 40
PK # General Information: Standard, Style Edition, Clad, Pine
Exterior Color / Finish: Standard EnduraClad, White
530 Interior Color / Finish: Prefinished White Interior
Glass: Insulated Low E Advanced Argon Gas
Viewed From Exterior Hardware Options: Standard Lock, White, No Sash Lift
Screen: Full Screen, InView
Grille:
Wrapping Information: Foldout Fins, Factory Applied, 3- 11/16" Factory Applied, Perimeter Length = 122 ", Glazing Pressure = 190.
Final Wall Depth: 3 - 11/16"
Rough Opening: 21 - 3/4" X 40 - 3/4"
FF -2 - Full Frame Tear Out Installation up to 70 UI Qty 1
EXTTRIM5 - New exterior trim 5/4 X 3 -1/2 PFJ Qty 1
LP -1 - Lead safe practices this opening under 150 UI Qty 1
For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com
Printed on 9/21/2012 Contract - Detailed Page 1 of 11
v The Commonwealth of Massachusetts
W° "` ""' °` Department of Industrial Accidents
�� " Office of Investigations
I x r 600 Washington Street
MINIAR
°� "' ",' Boston, MA 02111
1. ' - �' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricia /Plumbers
Applicant Information Please 'tint Legibly
Name ( Business /Organization /Individual):_ Pc= / /,7 /9i) r-,/ (5 / n 6
Li_ Address: / 6 /V ry /,-) 5 ( ?r e't 4
City /State /Zip: C:]ft'et) tF id iV A D /J0/ Phone #: -f /3• /7 -U /5.
Are you an employer? Check the appropriate box: Type of project ( equired):
1. 51. 1 am a employer with f �'j 4. ❑ I am a general contractor and I
f * have hired the sub- contractors b° ❑ New const ction
employees (full and /or part- time).
2 . C I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodelin'_
ship and have no employees These sub- contractors have 8. 0 Demolitiot'
working for me in any capacity. employees and have workers'
9. a. dition
[No workers' comp. insurance comp. insurance.t n Buildin g
required.] 5. ❑ We are a corporation and its 10.0 Electrical r or additions
3. n 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing r' or additions
myself. [No workers' comp. right of exemption per MGL l2.0 Roof repai
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidav't indicating such.
iContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not thole 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 poll y and job site
information. �,_
insurance Company Name: /--�:. ' r GS 11 t' r L.t. r t cl'i2
Policy # or Self -ins. Lic. #: (.1,) /- ,_; 'V � % 7‘‘ - o n Ex Date: Of (/- / 3
Job Site Address: , „. (ti (I CC, A) City/State/Zip: k t ; ,� 6') W,4
Attach a copy of the workers' compensation policy declaration page (showing the policy number and .1 piration date).
Failure to secure coverage as required under Section 25A of'MGL c. 152 can lead to the imposition of crimi al 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 IRDER 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 th= Office of -
Ilvestigations of the DIA for insurance coverage verification.
i do hereby certify under the pains and penalties of perjury that the information provided above is true an correct.
Signature: A 4 e,i''IV Date: q z c/ 7
Phone #: L ' — / - 1 '`1 ' 1
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit /License #
i
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbin . Inspector
6. Other
Contact Person: Phone #:
SEC 8 - CONSTRUCTION SERVICES
1 8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : GCt A
i License Number
- _ , . V : 013 C -,3 I- 701
Addr a C�
Expiration Date
—
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
1 7 3 CE Company Name l� Registration Number
Address n � Expiration Date
A. C (, � ' J . Telephone Lj / `J — 77 2
-
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 d" 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 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
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
r
New House ❑ Addition ❑ Replacement Wjndows Alteration(s) [] Roofing Di
Or Doors WI
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding [D] Other [0]
Brief Descriptio of I ro osed
Work: 1 r►S b .6 O f )
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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
l Je ff" re 7 G-rge `7 , as Owner of the subject
property
hereby authorize Pe- Ha Prod cc 4 t LiC
to act on -half, i - : - relative to work authorized by this building permit ap lication.
a
Si re Owner Date
\ ( t , 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 erjury.
Print Nam
a c q - -(2
Signature of Owner /Agent Date
v►
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
F 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 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT 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 ® DONT KNOW ® YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , 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 0
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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
CE�\/EL� City of Northampton Status of Permit:
(i .,......„ :6 : 7 1 --- E . Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
EP 2 4 Se Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
F uaroN NNVf1� 41 - 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:
This section to be completed by office
`I S v t cL � j Map Lot Unit
C� Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
J e-Tr.e 1 + a ■44._ r Cs r e ti YS /„) a r- d2 Aw- / N f-1+. kit 0t b 66
Name ( Prin Current Mailing Address:
A i r yr - sbi_fy 4-t-- Telephone
si.Mit
2.2 Authorized Agent: `' Xi() / ' /, ^
e fl AA A 0 te- - 1k_`� .1,)2 -STf eel � 6ce iig1° �
Name ( t)( , , 1 Current Mailing Address: M A c r
-�"`� `` � } qt -77z -n/ 3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
_ completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
0
4. Mechanical (HVAC) 6
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) _ S S 6x (Jx 0 O Check Number I 1/41 7 3 ( 0 3 S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
45 WARD AVE BP- 2013 -0337
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 316 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2013 -0337
Project # JS- 2013 - 000492
Est. Cost: $5500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft.): 15115.32 Owner: GREEN JEFFREY
Zoning: URA(100)/ Applicant: PELLA PRODUCTS, INC
AT: 45 WARD AVE
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC
GREENFI ELDMA01301 ISSUED ON: 9/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 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 9/24/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner