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35-221 FROM Berkshire Insurance Group CMON)APR 20 2008 10:41/ST. 10:38/No.7527318288 P 8 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the poticy(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(2001108) Page 2 of 2 INS025 Soaompaa FROM Berkshire Insurance Group (MON)APR 20 2009 10:41/ST. 10:39/No.7527319298 P S i `a i A ORD- CERTIFICATE OF LIABILITY INSURANCE 4%20%20°09' PRODUCER (413)773-9913 FAX: (413)774-3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MassOne Insurance: Agency HOLDER. THISOCERT FICATERDOES NOTOAM ND,CERTIFICATE 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 0 INSURED INSURER A:Continental Western Pella Products, Inc. INSURER B: ATTN: John Benjamin INSURER C: 155 Main Street INSURER O: 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. AGGREGATE T S SHOVM MAY HAVE D BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMBS _LM INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM DATE MWODPYY GENERAL LIABILITY EACH OCCURRENCE S 1,000,000.. X COMMERCIAL GENERAL LIABILITY PPR MI ESf TO RENTED $ 300,00.0 Em gz�mffence A CLAIMS MADE 51 OCCUR CPA020470112 1/1/2009 1/112010 MED EXP one S 15,000 PERSONAL BADVIN Y S 1,000,000 GA $ 2,000,000 GENERAL GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 X POLICY PR a LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,0 0 0,0 0 0 ANY AUTO (Ea accident) S A ALL OWNED AUTOS MILA020470212 1/1/2009 1/1/2010 BODILY INJURY S X SCHEDULED AUTOS (Per person) _ X HIRED AUTOS BODILY INJURY = __ X NON-OWNFAAUTOS (Per accident) PROPERTYDAMAGE S _ (Per accident) ; GARAGE I LIABILITY AUTO ONLY.FA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ " AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGRE GATE $ -- S DEDUCTIBLE S RETENTION S A WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETORfPARTNERIEXECUTIVE EL EACH ACCIDENT $ 500,000 OFFICERMIEMBEREXCLUDED? KCJL020470512 1/1/2009 1/1/2010 E-L DISEASE•FA EMPLOYEE S 500,000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLE SIMLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Operations usual to the sales 4 installation of doors fF windows. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE Ken Johnson EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL:: 34 Ladyslipper Lane 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Florence, MA 01060 FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATLVES. AUTHORIZED REPRESENTATIVE Robin Sargent/RMS ACORD 25(2001/08) a ACORD CORPORATION 1988 INS025(olo6)-oea Page 1 of 2 AL The Commonwealth of Massachusetts Department of Industrial Accidents 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 Name (Business/Organization/Individual): ��X /i^D��-� Address: /.5�:r Allaln 5�ree City/State/Zip6rcen-t i le( /V/P e14, Phone#: '�/� �'7�- 0/_-5_Y Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with !Z j:� 4. E] I am a general contractor and I. employees(full and/or part-time).* have hired the sub-contractors 6. F1 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 g. E]Demolition working for me in any capacity. employees and have workers' 9 E]Building addition [No workers'comp. insurance comp.insurance.$ required.] 5. F] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 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'corm.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: Gev eve//19 5 U Y` c`rn GC, ,o Policy#or Self-ins.W.#:r L�J G JD�d Expiration Date: Job Site Address: 3_ LG /t' > -er `a n'P, City/State/Zip floren& Attach a copy of the workers' codipensation 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ee u der the pains and penalties of perjury that the information provided above is true and correct. Signature: >� MUJA2 Date: DEC 2 9 2008 Phone#: /s— 207- X .202 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Board of Building Regulations and Standards HOME IMROVEMENT CONTRACTOR R -142279 4/2010 i;ITT lement Card PELLA PRODU MICHAEL SALT 155 MAIN STREET GREENFIELD,MA 01301 =...... Administrator Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Phone: 413-772-0153 Cell:413-834-8799 To: Building Inspector From: David White—Installation Manager Date: January 19, 2009 SUBJECT: Building Permit Applications & Designees Pella Products Incorporated is in the business of replacing windows and doors for our customers. Our process includes providing a building permit for each and every project. I am a licensed Construction Supervisor. Building permits will be applied for using my CSL #091496 and our HIC, # 142279. Please find a copy of my licenses below. tx icitClWtctt;-D ►u�rtiri;tnt a�Pu ar t. iRSW$O" . oa ConsttUCticn.supwvOor U01M w W. [li►res#ticW Fi1� tit�#Tft•5 :.:. ,etr aa�.a e�eia[a��ds a+[dre Taw;2410 Site Responsibilities and Terms of Sale Pella Products, Inc. 155 Main St. Greenfield,MA 01301 y k (413)772-0153 SITE RESPONSIBILITIES Customer: Ken Johnson Date: 04/06/2009 Order#: 73912EB231 Signature: Salesperson: Michael Balthazrr Signature: 1 50%Deposit required at time of order,balance due on the morning 60e last day of installation. 2 Payment is to be made to installation team. 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 postpone and reschedule the project. 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 Pella will call with approximate installation dates. These dates will be confirmed prior to install. 9 Unforeseen rot repair can be quoted on site as additional work 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 not binding until approved by Pella Products management 13 Pella will secure all necessary Building Permits Type of Installation: New Construction: (tear out installation) QCompletely 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) [l 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. Pella Will Owner Will [x1 F--J Deliver and unload products Q F-1 Place drop cloths in work areas x0 F-� Remove&reinstall interior and exterior trim if applicable x� F--] Remove&reinstall existing shutters and awnings by contract x0 F-� Remove existing product and adjust or modify opening as needed x0 D Provide all equipment necessary to install products x0 F� Cut all wood and other materials outside of home x F--J Install all products purchased xQ F-I Insulate and caulk around products Q F--J Remove stickers and perform initial cleaning of all glass surfaces Q [-� Demonstrate proper operation of products Q F-� Confirm that all products are in working order Q [—] Remove drop cloths,vacuum and remove all old products from premises 0 F--J Finish(paint or stain)product purchased Q Cut-back or tie trees,bushes,shrubs from exterior wall Q Arrange to have alarm system disconnected and reconnected El Q Arrange to have any plumbing or electrical repairs or changes by For all service needs, appropriate licensed contractor please call: (800)957-3552 0 0 Remove and reinstall existing window treatments,wall hangings and Please make sure you air conditioning units. mention that your project xQ Remove and reposition furniture in work area was installed by Pella x❑ Secure pets in a safe manner and reference your order x] Remove valuable/breakable items from work area number El 0 Remove snow from area of worksite if necessary SCTGN 8 G'0�1STRUi;TIONN SE 1±wE 8.1 Licensed Construction Supervisor:/ Not Applicable ❑ / Name of License Holder: '—Da(//G1i' t A(� License Number _ 155 01 n ' . n /� �r- D1��O l 11,3111 ( Address Expiration Date najjch) & yi ) 772.01`5_ Signature Telephone Re. I :er omi'il 'iruvementi 'r Not Applicable ❑ �� rb ul ,c rzc - 1�1Z2�G1 Company Name Registration Number 16-5 M4/"n S1. 6r1-en ,,ld Hil �312gLlo Address Expiration Date Telephon�� 3�/�� SC�1OM i0t'�IifRKERS' COM�'ENATION IlySU12ANCEAFFIC3AVlT(M GLz c 15t§<25G(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....... M( No...... ❑ 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 SEG,,7 0 5 DESCRIPT[ON OF I'R�OPtOSED WORD check ail a0plica[ile)r -- t New House ❑ Addition ❑ Replacement W'dows Alteration(s) Roofing El Or Doors lV Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[❑] Brief Deq iption of Proposed , Work:_ �o�4Gr1 0 li�ii7G D Od✓• /n4 'LKi S f Z. Oyenfl) 'A St 41 ;f fe- 0/7qn�. Alteration of existing bedroom Yes_ZNo Adding new bedroom Yes ✓F 0 Attached Narrative Renovating unfinished basement Yes ✓ 0 Plans Attached Roll -Sheet 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 SECT, [QN 7a OWNER AUTHOIIZATI©N, TO t3E CON(PLETED WHEN OWNERS AGENT ORnGONTRr4GTOR AFPLI)TSFQR;BUILDING°flEFM1.T . 1.- nSo n as Owner of the subject property / A —/ hereby authorize e— �I'� CXJ C.-A to act on my behalf, in all matters relative to work authorized by this building permit application. ! s " -elo/I Cot) Z C) Signature of Owner Date 1, lqr lie yo/A i ur o& ?114 Prb C/oc h7<- 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. Nei 1�e 341 ma2n'' Print Name `n. _ ` A� 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 � �---1 % Open Space Footage % ''[[ (Lot area minus bldg&paved � � 1 parking) #of Parking Spaces Fill: gig volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:E--= IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page � and/or Document #i_ . . 1 _�___ 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 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 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. City of Northampton Building Department 212 Main Street Room 100 a: , Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SE O'"I 1 I tN OFtMATiON 1.1 Property Address: f � 3y LadysI, F/oren C_p- 0/0& . SECTIQN 2 PR�P1✓RT�1�-OWNERSHIP/AUTHORIZ�D,gGENT`,`, _ 2.1 Owner of Record: /'en J&Aason `/ ' ne-- Name(Print) CurXnt M i' A ss See_ 'S/Q n e 1c)nh74 c Telephone Signature 2.2 Authorized Agent: ?,oil a /orb CI u c f5 �n� • 2 / �i n tly'rfen�i� Name(Print) Current Mailing Address: Signature � � - y13) 714Y 7&07 Telephone SE0TION3 „EST[MATED CON,STRUCTION.COSTS,. Item Estimated Cost(Dollars)to beOfficEaLUse;OrilX completed by ermit applicant 1. Buildinga Btilld�n Perrritt Fees X700. 00 ) 2. Electrical (b)Estiftaafd T�ttos#lof �Crpnstruittgrt from, 6; 3. Plumbing )3� jtpgeieFe 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 1 '570 0, 00 . Ci tunrb h;' '. Thls,Sectlan,�ctr Offrcfal Us'e Una,., .. Building.Permit Number. bate Issued' IF 5ignatare: 0 �� p�. Bt�ddmg Comriussione�llnspector of Buildings z ,tiYSER LN '" BP-2009-0872 GIs#: COMMONWEALTH OF MASSACHUSETTS a :131ock: 35 -22117 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-2009-0872 Project# JS-2009-001274 Est. Cost: $5700.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC Lot Size(sq. ft.): 39552.48 Owner: JOHNSON KENNETH R&DIANE F Zoning: SR(100)//WSP II Applicant: PELLA PRODUCTS, INC AT. 34 LADYSLIPPER LN Applicant Address: Phone: Insurance: 240 MOHAWK TRAIL (413) 772-0153 GREENFIELDMA01301 ISSUED ON:412412009 0:00:00 TO PERFORM THE FOLLOWING WORK.-Replace Sliding 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 si nature: FeeType• Date Paid: Amount: Building 4/24/2009 0:00:00 $35.0033095 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo