44-080 (2) 30 AUTUMN DR BP-2021-1499
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-080 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2021-1499
Project# JS-2021-002489
Est.Cost: $5860.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 096558
Lot Size(sq. ft.): 10018.80 Owner: JUDGE KRYSTYNA
Zoning: Applicant: PELLA PRODUCTS, INC
AT: 30 AUTUMN DR
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFI ELDMA01301 ISSUED ON:6/16/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 5 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. 1
)2 TO
Certificate of Occupancy Sil;natur I I
FeeType: Date Paid: Amount:
Building 6/16/2021 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
C),(\
"/G 1
1 , The Commonwealth of Massachusetts 209 7 .
W
Board of Building Regulations and Standards r
Massachusetts State Building Code, 780 CMR tiq,,,% ! ICI I? I
o or
Building Permit Application To Construct,Repair,Renovate Or Dem. s &e F Rev'••d Mar 011
One-or Two-Family Dwelling 0,0o).o
4,0
This P rmit Number: 6,i}t`-f7 l% tion For Official Use Only
BuildingDate Applied:
�Ui� ` K l 61,-)5-ZOZ/1
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
30 AAArwn 0Y1‘re NNAmm', Oo4I bfo`. vo eoL - oov !
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zo ' g,lnformation: 1.4 Property Dimensions:
£ i Sf'1►tt MI(Uri-ha t
Zoning District Proposed Use Lot Area(sgft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 0 r'of Record:
iM i�c‘ Ju d c,e� t cN�r csL l�,' G \OLD
Name( nt) City,State,ZIP
'50 ( a n 0C. il 13 9 71-1 7/S/ kj t,td e 13&1',rrYncall- e,1-#
No.and Street Telephone Eil Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition ❑ Accessory Bldg.0 Number of Units Other Specify: hW I ct cams.,Y±-f"
Brief Description of Proposed Work2:(Re,pp)(ic v r, 5 e,X i S�r\c A.Nr-Ncv 1�
O9e..0\IN c\.S W i a-1r, �W C�CAnW S VD��tr.� \rt 1
YQLc 2X .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 5' tP. O 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ CIStandard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: tii
Check No.1 glitlhe,ck Amount: 4 Cash Amount:
6.Total Project Cost: $ 58\(D 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Cs • 0 VQ 558 3 /o i la a_
S S License Number Expiration Date
Name of CSL Holder ,
List CSL Type(see below) Vl
1 C) veCJcZJ St-
No.and Street TYPe Description
& art MA C 0 3u I U Unrestricted
es Restricted
1 (Buildings upel 35,000 Cu.ft.)
1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
— WS Window and Siding
SF Solid Fuel Burning Appliances
LI I bIUD/6?) NI-3 i 1 peywik pflasaUs I Insulation
Telephone Email address , Cr,vfl D Demolition
5.2 Re stered Home Improvementl Contractor(HIC) /1/ a .-, i 9 Ia -
el lol Pro uuvl J l nG' HIC Registration Number Expiratiab Date
HIC C nvany Name or HIC Registrant Name
K Malmo S • pomiitc&_peth.saks Cain
No. d Street
n('ii h-el c{ /VIA Q 13 U I L//3 n al OLC3 Email address
Cityere('
own,State,ZIP Telephonee.ja 377
SECTION 6: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 Iss ce of the building permit.
Signed Affidavit Attached? Yes No 0
SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
I,as Owner of the subject property,hereby authorize Pe I i ci Pod u G Ic.
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's 1Qamme(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this ph tion is true and accura the best of my knowledge and understanding.
e---4 .0 /.2r/o2d
Print Owner's or A horized Agent's Name(El nic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
Contract - Detailed
iff* Pella Window and Door Showroom of Greenfield Sales Rep Name: Langan, Brandon
240 Mohawk Trail Sales Rep Phone: 413-774-7231
Greenfield, MA 01301-3209 Sales Rep Fax: 413-774-6348
Sales Rep E-Mail: blangan@pellasales.com
Customer Information Project/Delivery Address Order Information
Krystyna Judge Judge Krystyna 30 Autumn Dr Florence MA - Quote Name: Vinyl 250 Series 1396206
30 Autumn Dr 30 Autumn Dr
Order Number: 739W3FL081
Florence, MA 01062-9720 Lot# Quote Number: 14093656
Primary Phone: (413)5847159 Florence,MA 01062 Order Type: Installed Sales
Mobile Phone: County: Payment Terms: C.O.D.
Fax Number: Tax Code: MASS
E-Mail: kjudge123@comcast.net Quoted Date: 5/17/2021
Great Plains#: 1006239977
Customer Number: 1010085193
Customer Account: 1006239977
Customer Notes: Price includes removal and disposal of old products,new products,interior/exterior trim where necessary,isntallation,and building permit.
Total-$5,860.00 for special 20%and 3%veteran discount.
50%deposit and remaining due upon completion.
Vinyl 250 series Single hung windows.
Modified pocket on 3 wide unit in living room.Exterior pockets replcaements on rest.New interior stops early american living room and prefinish white for rest.New exterior
capping white on all units.
Home built in 1972.Led safe practices.
For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com
Printed on 5/18/2021 Contract-Detailed Page 1 of 9
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
customer: nrystyna Juoge rroject'Jame: Judge Krystyna 30 Autumn Dr Florence MA Order Number: 739W3FL081 Quote Number: 14093656
Line# Location: Attributes
10 Living Room Pella 250 Series, 3-Wide Single Hung, 76.375 X 45.5,White Qty
1
1:Non-Standard SizeNon-Standard Size Single Hung,Equal
. PK# Frame Size: 25 1/8 X 45 1/2
14-5 General Information: Standard,Vinyl,Block,Foam Insulated,3 1/4",3 1/4"
-4 S IH 2089
Exterior Color/Finish: White
25 12b:' W i Syr" Interior Color/Finish: White
Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Hardware Options: Cam-Action Lock,White,No Limited Opening Hardware
Viewed From Exterior Screen: Half Screen,Conventional Fiberglass
Performance Information: U-Factor 0.27,SHGC 0.29,VLT 0.55,CPD PEL-N-208-00072-00001,Performance Class R,PG 35,Calculated Positive DP
Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code
requirements
Grille: No Grille,
Vertical Mull 1: FactoryMull, 1/2"Joining Mullion
2:Non-Standard Size Fixed Direct Set
Frame Size: 25 1/8 X 45 1/2
General Information: Standard,Vinyl,Block,No Foam Insulated,3 1/4",3 1/4"
Exterior Color/Finish: White
Interior Color/Finish: White
Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Performance Information: U-Factor 0.26,SHGC 0.31,VLT 0.60,CPD PEL-N-209-00049-00001,Performance Class CW,PG 50,Calculated Positive DP
Rating 50,Calculated Negative DP Rating 50,Year Rated 08111
Grille: No Grille,
Vertical Mull 2: FactoryMull, 1/2"Joining Mullion
3:Non-Standard SizeNon-Standard Size Single Hung,Equal
Frame Size: 25 1/8 X 45 1/2
General Information: Standard,Vinyl,Block,Foam Insulated,3 1/4",3 1/4"
Exterior Color/Finish: White
Interior Color/Finish: White
Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Hardware Options: Cam-Action Lock,White,No Limited Opening Hardware
Screen: Half Screen,Conventional Fiberglass
Performance Information: U-Factor 0.27,SHGC 0.29,VLT 0.55,CPD PEL-N-208-00072-00001,Performance Class R,PG 35,Calculated Positive DP
Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code
requirements
Grille: No Grille,
Wrapping Information: Pella Recommended Clearance,Perimeter Length=244".
Frame Size:76.375"X 45.5"
LP-1 -Lead safe practices this opening Qty 1
EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1
MP-9-3 Wide Modified Pocket Installation 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 5/18/2021 Contract-Detailed Page 2 of 9
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
t,ustomer: nrystyna.,uuge rrojeut Name: Judge Krystyna 30 Autumn Dr Florence MA Order Number: 739W3FL081 Quote Number: 14093656
Line# Location: Attributes
15 Bedroom 1 Pella 250 Series, Single Hung, 35.5 X 37.5,White Qty
2
F-71:Non-Standard SizeNon-Standard Size Single Hung,Equal
►a7 PK# Frame Size: 35 1/2 X 37 1/2
i y 2089 General Information: Standard,Vinyl,Block,Foam Insulated,3 1/4",3 1/4",Sill Adapter Included,Head Expander Included
lt
Exterior Color/Finish: White
Interior Color/Finish: White
I Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Hardware Options: Cam-Action Lock,White,No Limited Opening Hardware
Viewed From Exterior Screen: Half Screen,Conventional Fiberglass
Performance Information: U-Factor 0.27,SHGC 0.29,VLT 0.55,CPD PEL-N-208-00072-00001,Performance Class R,PG 35,Calculated Positive DP
Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code
requirements
Grille: No Grille,
Wrapping Information: Pella Recommended Clearance,Perimeter Length=146".
Frame Size:35.5"X 37.5"
LP-1 -Lead safe practices this opening Qty 1
EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1
PF-2-Exterior Pocket Installation Qty 1
Line# Location: Attributes
20 Office Pella 250 Series, Single Hung, 35.5 X 37.5,White Qty
[ 2
1:Non-Standard SizeNon-Standard Size Single Hung,Equal
PK# Frame Size: 35 1/2 X 37 1/2
N- 2089 General Information: Standard,Vinyl,Block,Foam Insulated,3 1/4",3 1/4",Sill Adapter Included,Head Expander Included
cr) awl
Exterior Color/Finish: White
Interior Color/Finish: White
Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Hardware Options: Cam-Action Lock,White,No Limited Opening Hardware
Viewed From Exterior Screen: Half Screen,Conventional Fiberglass
Performance Information: U-Factor 0.27,SHGC 0.29,VLT 0.55,CPD PEL-N-208-00072-00001,Performance Class R,PG 35,Calculated Positive DP
Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Egress Does not meet typical United States egress,but may comply with local code
requirements
Grille: No Grille,
Wrapping Information: Pella Recommended Clearance,Perimeter Length=146".
Frame Size:35.5"X 37.5"
LP-1 -Lead safe practices this opening Qty 1
EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1
PF-2-Exterior Pocket Installation 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 5/18/2021 Contract-Detailed Page 3 of 9
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
customer: mrystyna.,uuge rroject(Jame: Judge Krystyna 30 Autumn Dr Florence MA Order Number: 739W3FL081 Quote Number: 14093656
kJ Project Checklist has been reviewed
Krystyna Judge Brandon Langan Order Totals
,. a e (Please print) r_PJFIRA,A Liep Name (Please print) Taxable Subtotal $2,629.65
stylA.a. ,,ltiilt, f VatA,dbin, 144A/tLt, Sales Tax @ 6.25% $164.35
Customer Signature Pella tg1es1'1e'p`Signature
5/18/2021 5/18/2021 Non-taxable Subtotal $3,066.00
a+ Total $5,860.00
fj—:—cuSlgned by: Date Deposit Received $0.00
liu ►ik, Amount Due $5,860.00
�Cr@ ' RfAiii3Voval 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 5/18/2021 Contract-Detailed Page 9 of 9
DocuSign Envelope I•D:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
Project Name: Krystyna Judge Today's Date: 5/18/2021
Quote#: 14093656
This is a "Do-it-Yourself" project all dimensions, attributes, installation, and
disposal are the responsibility of others.
Signature:
We cannot guarantee that existing window treatments(i.e.Shades, Blinds,and Interior Shutters)
will fit on new Pella Windows/Doors.
This is an Installed project
Condition of Work:
1.50%Deposit required at time of order.
2. Final payment is to be made to installation team on the final 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.We cannot guarantee/will not your existing shades and blind will fit in your new windows.
6.Due to inclement weather or site conditions,it may be necessary to reschedule.
7.We cannot and will not guarantee specific dates or days of the week for installation.
8.Time given to complete a job is an estimate,extension of time is possible.
9.An install appointment will be confirmed at Verification.A courtesy reminder call will be placed 3-days prior.
10.Unforeseen rot repair will be quoted on site as additional work via a Field Change Order. Rot repair or additional installation
charges are due at the time of installation and cannot be financed through GreenSky Financing,Check or Credit Card Payments only.
11.Upon Substantial Completion final payment is due,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.
12. In the event 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.
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
Type of Installation: X
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/door.
Pocket Install:(sash replacement,existing frame remains)
x Remove interior or exterior window stops,install new window in existing sash opening, re-use existing or replace
window stops.Some glass loss will occur.
Lead Paint Discloser:
x 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.
Are there children under the age of 6 or women who are pregnant?
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
•
Condition of Work(Continued):
Owner Will:
Authorize installation of Yard Sign 7-10 days prior to installation date and removed after installation is complete.
Ensure someone over age 18 is present at all times while Pella Employees are in the home
Cut-back or tie trees,bushes,shrubs from exterior wall (Grass and Shrubs may be damaged during construction)
Have alarm system disconnected and reconnected-Pella Products can re-route wires but cannot reconnect
Have any plumbing or electrical repairs by appropriate licensed contractor-$500 charge if unprepared on 1-Day job
_Remove and reinstall window treatments,wall hangings and A/C Units-4-5 feet in front/1 foot to side with clear path
Remove and reposition furniture in work area
Os _Secure pets in a safe manner
I . Remove valuable/breakable items from work area
L _Remove snow from area of worksite if necessary
Pella Products Will:
Deliver and unload products
Place drop cloths in work areas
Remove and reinstall interior and exterior trim if applicable
Remove and reinstall existing shutters and awnings by contract
Remove existing product and adjust or modify opening as needed
Provide all equipment necessary to install products
Cut all wood and other materials outside of home
Install all products purchased
_Insulate and caulk around products
Remove stickers and perform initial cleaning of all glass surfaces
Demonstrate proper operation of products
�4 OS Confirm that all products are in working order
J —Remove drop cloths,vacuum and remove all old products from premises
_Installer will collect balance due on final day of installation
PRE-FINISH DISCLAIMER
Stained and paint color samples are produced as accurately as possible: however,actual colors may vary from batch.
Because wood is a natural product,each window or door will display its own personality with regards to variation in
color,texture and grain pattern. Natural wood variations include distinctive grain patterns or unusual shadings in color.
Due to the nature of using natural products, Pella Windows and Doors cannot be responsible for the actual degree of
variation that may occur in your purchase.
-DocuSigned by:Signature: wI,. Today's Date: 5/18/2021
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
• PRE-RENOVATION FORM
Occupant Confirmation
YEAR OF CONSTRUCTION (check one) ACTUAL YEAR HOME CONSTRUCTED 1972
I certify that my home was built BEFORE AFTER Dec. 31, 1977 PRESUMED LEAD X
Property Address: 30 Autumn Dr Additional Notes:
Florence, MA, 01062
If BEFORE is selected,continue to LEAD TESTING APPROVAL.
If AFTER is selected,proceed to the PRINT NAME/SIGNATURE section.
LEAD TESTING APPROVAL
I agree to have Lead Testing performed in my home by Pella Products,Inc.
I understand the Lead Testing protocol may cause:
Cuts and chips through the existing finish on and around the windows and doors included with this project;including interior
and exterior trim,painted walls,and exterior siding.
Staining or discoloration of the existing interior and exterior finishes occurring in the tested areas.
Interior and exterior trim to be damaged due to removal to provide access for the Lead Testing Protocol.
TESTING RESULTS
I have reviewed the results of the Lead Testing accomplished by the above named Certified Renovator.
I understand the results of my test will be sent to be me,via U.S.mail,within 30 days of the renovation.I have been shown the
testing swabs as used for this testing and understand if any test swab indicates a shade of red,lead is assumed present and EPA
Renovation,Repair and Painting Guidelines apply.
CHECK ONE OF THE FOLLOWING:
(A) My home tested positive for lead. I request that Pella Products,Inc use the lead-safe work practices required
by the EPA's Renovation,Repair and Painting Rule and will be supplied a pamphlet on lead hazard.
(B) My home tested negative for lead. I understand that Pella Products,Inc will not be required to use the lead-
safe work practices required by the EPA's Renovation, Repair and Painting Rule and will not be supplied with a
pamphlet on lead hazard.
PAMPHLET RECEIPT u
X I have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead
hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the
work began. [Tenant occupied dwellings require a separate notification process.]
RENOVATOR'S SELF-CERTIFICATION
(for tenant-occupied dwellings only)
Krystyna Judge Instructions to Renovator:If the lead hazard information pamphlet was delivered
Printed Name of Owner-Occupant but a tenant signature was not obtainable,you may check the appropriate box
below:
,-DocuSigned by:
Declined by tenant;a copy was left with the tenant
Ilia
Unavailable for signature;good faith effort made and have left a copy
�igHr�ca1 t, '�'4��`Owner-Occupant at the residence for the tenant
Mailing Option;pamphlet must be mailed at least 7 days before
5/18/2021 renovation and mailing must be documented by a certificate of mailing
from the Post Office.
Signature Date
[This is an alternative to delivery in person to the owner and/or tenant.]
DocuSign Envelope ID:55DE2C12-4E8C-470A-AFF3-C924D528D6C8
Pella Products Inc.
155 Main Street
Greenfield, MA 01301
To Whom it may Concern:
Krystyna Judge , as property owner, give permission to our contractor, Pella
Products Inc.to obtain a building permit for the installation of windows and/or doors in my home.
Located at; 30 Autumn Dr
Florence, MA, 01062
Please accept this letter in place of my signature on the permit application.
Thank you,
,-DocuSigned by:
�,. /..
Signature: Sbib ��D5 189594B1D4DD_.
Date: 5/18/2021
PELLA PRODUCTS INC.
155 MAIN STREET
GREENFIELD, MA. 01301
Date: 3 a J
To: C' N U‘(\ \ACar\9"\-vti
Subject: Disposal of Debris
The purpose of this letter is to certify that all debris from any project
undertaken by Pella Products, Inc. in your town will be transported to
a dumpster at our main facility; 155 Main Street, Greenfield, MA.
Pella Products, Inc. is under contract with Waste Management of Massachusetts
For the disposal of the contents of this dumpster.
Very truly yours,
PELLA PRODUCTS, INC.
Denise Chortler
Accounting Manager
The Commonwealth of Massachusetts
==.6
Department of Industrial Accidents
` Office of Investigations
Lafayette City Center
_..,, ; 2 Avenue de Lafayette, Boston, MA 02111-1750
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: Type of project(required):
1.El I am a employer with 50 4. Q I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑■ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
p �' 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
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.
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: EMC INSURANCE COMPANIES
Policy#or Self-ins. Lic. #:6H 15382 Expiration Date:0 1-0 1-2022
Job Site Address: 3D P11 duLvv\r Oc. _City/State/Zip: IF\()(7.,)(\_C
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 u der the pains and penal " f perjury that the information provided above is true and correct
Signature: Date: .5 -a - 321
Phone#: 3 7. O
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Elumbing
Inspector 6.0Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
Revised 7-2019
www.mass.gov/dia
Pella Products, Inc.
155 Main Street
Greenfield, MA 01301
Office:413-773-1157 Ext.317 Cell:413-834-8799
To: Building inspector
From:Trevor Bross—Installation Manager
Date: February 21,2021
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#CS-096558 and my
HIC# 142279. Please find a copy of my licenses below.
Commonwealth of Massachusetts Construction Supervisor
Division of Professional Licensure Unrestricted-Buildings of any use group wM idi caM
Board of Bolding Regulations and Standards less than 30,000 cubic test(9!1 cubic torten'at endege0
ConslPi t(Visor space.
CS-096558 " " Eitpires:03/0112022
TREVOR BROSS
10 GEORGE STREET
GREENFIELD MA 01301
Failure to possess a current edition of the Massachusetts
Com miss io net ..�< /.,y,...t I", State Building Code is cause for revocation of this license.
p e,. For information about this license
Call(617)727-3200 or visit www.mass.govldpl
✓/JP ri-/Y)7I7JMJI/P?l� eye.��/J-i)!J'CYJtl3Plf3
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
142279 03/23/2022 1000 Washington Street -Suite 710
PELLA PRODUCTS,INC. Boston,MA 02118
II
eD f
ELWIN HERRINGSHAW - ' Z/`
155 MAIN STREET oe.et'a ''4;.G4a
GREENFIELD,MA 01301 Undersecretary Not valid without signa e
Each Installation will be staffed by our installers who are all licensed in accordance with current building codes. Below
listed are our installers and their license numbers. Please accept these individuals as my designees.
Willard Brown CS106010 Vladimir Shevchuk CSSL099209
Scott Bowdish CSSL100232 Bill Leger CS89338
Christian Lambert CS065102 Robert Kairnes CS113305
Igor Kravchuk CS094911
Pella Products Inc.
Attn: Accounting Dept. Fax 413-773-3740
Payment/Reimbursement Request Form
Requesting: Has Credit Memo been issued?
Y ►'
Employee Expense Check Has order been revised/cancelled? Y h
1;1 Vendor Check
Send Customer a Refund Check
!` Petty Cash Check
Process a Credit Card Refund/Reimb.
Cash on Hand
Sales Rep: Brandon Customer Number: 1006239977
Payee Name City of Northhampton Date 5/28/2021
Address 1 212 Main St Social Security No.
Address 2
City, State,Zip Northhampton MA 01060
Send Check To: Crystal @ Store#53
Date Description Amount DO NOT USE
PERMIT FEE $40.00 ACT
Order#739W3FL081 $
Krystyna Judge ACT
30 Autumn Dr $
Florence, MA 01062 ACT
ACT
ACT
ACT
TOTAL $40.00 Approved
Pay Date
VCH
For Office use only:
Date Account Balance Dynamics
OMS
Acct Ext Initials
Contacts: Human Resources
Updated 6-12 F