46-058 (15) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
JeW` Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
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:
49 4. ■ I am a general contractor and I Type of project(required):
1.9 1 am a employer with ❑ g 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 g. ❑ Demolition
working for me in any capacity. employees and have workers'
9. E] Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑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 Replacement Windows&Doors
employees. [No workers' 13.❑■ Other
comp. insurance required.]
*Any applicantthat 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: Hanover Insurance Group —
Policy#or Self-ins.Lic. #:WHN-9399766-02 Expiration Date:01/01/2016
Job Site Address: 3Q'5 Mnun� To,-, Rd City/State/Zip: N!xi'{)o_,,-,r,fl}qaTf`'(� cytcx p
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: VI�1 V Date: /15
Phone#: 9 i3` - 7q-7, 31 x Ica
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: E'W i!1 f �Q�f 1r1(�q� .) I oo?3
License Number
Address pp Expiration Date
C. 13-�1�13�IIS'7 x vOD
Signature ° Telephone
94 fZ6011MeredxFom. i3tfirt + mdrttorttrctfr ... °..., , Not Applicable ❑
Pella P(-QC1\JC K Inc cKaa-7q
Company Name Registration Number
Address ('eta A,� Expiration Date
C7i'�.n1 -eta I M� U1�� Telephone�►3 _'17�-IIs-�
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 buildi permit.
Signed Affidavit Attached Yes....... 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 verson 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 buildine 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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement W' doves Alteration(s) Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs (p] Decks [p Siding[O] Other[0)
Brief Description of Pro�pos�e_d�, .1,t-` 1 _i_
Work: Q P] 4si °`—s�tLr1 Gldo�S VSinu l^t Z1�i`otln; n�na Wig �� D tlfardP [ I&InP 5 ft
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative A/!/A d Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet IVI
6a 1f.New h 'usi:lr rciJ ti Xto.Q" isiri � Ir� +dte
I] iin
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Num er of Bathr ms
c. Is there a garage attached?
d. Proposed Square footage of new constructi n. Dimensio
e. Number of stories?
f. Method of heating? Firepla?ckEnergy oodstoves Number of each
g. Energy Conservation mpli �ce. Massc Compliance form ached?
h. Type of construction
i. Is construction within 100 . of wetlands. Yes No. I ction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finish grade
k. Will building conform to the Building and Zoning regul tions? Yes No.
I. Septic Tank City Sewer Privat well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, t `Q'M y`A2�'LA t`S�i as Owner of the subject
property
hereby authorize I CM (k frc GtU'4 C
to act on my b If, ' II matters r ive t w k uthorized by� building permit application.
I�
Signature of„caner Date
I, �Win I� �Ylnq�'1LutJ 6T PCl(C� �ft7�V �nC as Owner/Authorized
Agent hereby declare that the,-dttatements 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.
I i ri
Print Name /
Signature of Owner/Agent t Date i
V
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
�i� This column to be filled in by
Res 1061 Al 0-i �S/�`-� Building Department
w. .
Lot Size mow. f
'144
Frontage . .... _._. ... . .�_._ .. __. _ +
Setbacks Front }
-
Side L:__"_
R .... L .. R
rI�
.a
Rear
Building Height
V " .' �
Bldg. Square Footage %
Open Space Footage oa
.-
(Lot area minus bldg&paved 1 r €
arkin
#of Parking Spaces _
Fill:
r s �l
volume&Location ..-- m_,_ _.. ._
A. Has a Special Permit/Variance/Finding er been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued (
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES Q
IF YES: enter Book Page; and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW (?(YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingeen, 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.
L-maj-1240 f Northamptonng Department Main Street oom 100
mbin prn�t� Gpton, MA 01060 M Fax 413-587-1272
y
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Cc 3 tAwn TCm Rd This section to be completed by office
a1 VQ'U Map Lot Unit
Zone Overlay District
EIm St.District
CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MAN GI �l S03 MWO+ TiNn RC( 0101W,
Name(Pri ! Current Mailing Address:
3-3q 79.
Telephone
Signature
2.2 Authorized Aaent:
wiii HerrinAikc w ►'S�) Mow% 3 _ Gren.,�ield PJI I� Gl�v(
Name(Print) Current Mailing Address:
�1i3 -773- IIS7 K3�5
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing U Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) ,ctp Check Number Ito W d5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
503 MOUNT TOM RD BP-2015-1140
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:46-058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-1140
Project# JS-2015-002145
Est. Cost: $10293.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 100235
Lot Size(sq. ft.): 117612.00 Owner: GLAZEWSKI HELEN S&MARY
Zoning-: Applicant: PELLA PRODUCTS, INC
AT: 503 MOUNT TOM RD
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON:511912015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 2 REPLACEMENT ENTRY DOORS
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 Occupant Signature:
FeeType: Date Paid: Amount:
Building 5/19/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner