38B-269 (4) The Commonwealth of Massachusetts
Department of IndustrialAccidents
z Office of Investigations
fit I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Name (Business/Organization/Individual): Pella Products, Inc.
Address: 155 Main Street
City/State/Zip:Greenfield, MA. 01301 Phone#:413-772-0153
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 49 4. 0 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. R Remodeling
ship and have no employees These sub-contractors have g. 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.❑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.
lContractors 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:Hanover Insurance Group
Policy#or Self-ins. Lic. #:WHN-9399766-02 Expiration Date:01/0-11/2016 /
Job Site Address: 109 5b .5 City/State/Zip: �t��l�` , /r Tom✓
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 c ify under the p nd penalties of perjury that the information provided above is true and correct'
Sign afore: '� Date:
Phone#: Above
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:
� ���w C`S/� /'`�
License Number
r
Address Expiration Date
Signature P L Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
/ST 11441rJSt(\0-� `rCen -t A Qty
Address Expiration Date
Telephone 4-//,3 ' ��
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 (Jwn Exem tion
The current exemption for"homeo Fs"was extended to include Owner-oV vied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage ark individual for hire who does ft�possess a license,provided that the owner acts
as supervisor.CMR 780 Sixth Edition tion 108.3.5.1.
Definition of Homeowner:Person(s)who own 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 dwellin attached or detached structures accessory to such use and/or farm
structures.A erson who constructs more than one me in two- ear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, 4form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the bui in ermit.
As acting Construction Supervisor your presence on tie/job site ill be required from time to time,during and upon
completion of the work for which this permit is issue
Also be advised that with reference to Chapter 15 /(Workers'Compe ion) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death) the Massachusetts Gener Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this rmit.
The undersigned"homeowner"certifies a assumes responsibility for compli, e with the State Building Code,City of
Northampton Ordinances,State and Lo 1 Zoning Laws and State of Massachusett eneral Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement dows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [C3] Decks [Q Siding[O] Other[C]J
Brief De cri lion of Proposed (.t'S1��� Xi S `rr^� o re-,11 VXA S , /V : rS-tY-uc rw C
Work: ( (a�Q f141e_ 1 a � � !N ne�c } L*: 2j 1"1-u�o. 3' bi1/�.�)
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 buil ' : One Family Two Family Other
b. Number of room n each family unit: Number of Bathrooms
c. Is there a garage atta d?
d. Proposed Square footage of n 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. s 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, LGtA.Aisc as Owner of the subject
property n
hereby authorize Qi G: f�'�c�j f""T(-
s {1 Cr
to act on m b half, in all matters relativ to work authorized by this building permit application.
a, :: [ l 114 1 I'
Signature of Ow Date
J LC/l4c 1(6( � _V4(-r as Owned thor��i._
A en ereby 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 Owne gent Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
�v 11
Existing Proposed Required by Zoning
ibis 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 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 0 DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
' a orthampton Status of Permit:
DBu i Department Curb Cut/Driveway Permit
ain Street Sewer/Septic Availability
. 3 Ro m 100 Water/Well Availability
n, MA 01060 Two Sets of Structural Plans
®�ryNortr, 4* 0 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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
w �✓ � %1. 31.0• l 6 '10
Telephone
Signature
2.2 Authorized Aaent:
vr7,, /' Ar, Pr6 A C+5� � te, _ I.<5
Name(print) Current Mailing Address:
P L113
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a)Building Permit Fee
2. Elect-i_-al (b)Estimated Total Cost of
Construction from 6
3. Pluming Building Permit Fee
4. Mech-nical (HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) O CSC: , C)� Check Number �3 �
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signat,-iw:
Building Commissioner/Inspectorof Buildings Date
242 SOUTH ST BP-2015-0770
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-269 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2015-0770
Project# JS-2015-001496
Est. Cost: $20000.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 100235
Lot Size(sq. ft.): 7056.72 Owner: WULSIN LAWSON REED JR
Zoning. URB(100) Applicant: PELLA PRODUCTS, INC
AT. 242 SOUTH ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON:113012015 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 1/30/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
242 SOUTH ST BP-2015-0770
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-269 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-0770
Project# JS-2015-001496
Est.Cost: $20000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 100235
Lot Size(sg. ft.): 7056.72 Owner: WULSIN LAWSON REED JR
Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC
AT: 242 SOUTH ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON.113012015 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 1/30/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner