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18-002-037 BP-2024-1141 87 PINES EDGE DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18-002-037 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2024-1 141 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2024 Contractor: License: Est.Cost: 12940 PELLA PRODUCTS, INC 096558 Const.Class: Exp.Date:03/01/2026 Use Group: Owner: MORRIS JESSICA Lot Size (sq.ft.) Zoning: RI/RR Applicant: PELLA PRODUCTS, INC Applicant Address Phone: Insurance: 155 MAIN ST 413-512-5968 61115382 GREENFIELD, MA 01301 ISSUED ON: 09/04/2024 TO PERFORM THE FOLLOWING WORK: 3 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS.Signature: i/Z.. Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner /(9,6b p ‘1. The Commonwealth of Massach efts se,4) l',C- OR Board of Building Regulations and tand4fds ` Massachusetts State Building Code, .0, <-70 ONIS • LITY U Building Permit Application To Construct, Repair, Renov e`O.r olish f R ised, ar 2011 One-or Two-Family Dwelling J This Section For Official Use Only ':'Qobr,, Building Permit Number: 44Q� 7' - //'f/ Date A lied: ° S ✓T u-B ilaing Official(Print Name) Signature Dat SECTION 1: SITE INFORMATION �1..1 Pr erty Address• 1 1 ' , 1.2 Assessors Map&Parcel Numbers L` elf' e Tc. J f-1,-'c cu i ,-t. Li a Is this an accepted street?yes no Map Number Parcel Number 1.,3 Z,onigg lnformat> 6L�2 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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 ifves❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 'Z.aC(Print)40c _ rnocr,`5 A)v( r.IAtr. 1-e- j t , AAv t, (cco Namer i City,State,ZIP f�, ' E-6 c. 0 l 3-3i "7 l�'t UG��Xc sFie h04-1VIrc LL%.-c o.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) %l Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: r e,t't,,,C r\c� 2 - , ,A.);cU (_,L :.&�5 ¶ti�1-9 Q 7 5 � U Oil( S J u— c -o< = C). SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ i9,ci(.f0.cisq 1. Building Permit Fee: $ Indicate how fee is determined: i ❑ Standard City/Town Application Fee 2. Electrical $ . ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees , / Check No. heck Amount: -0 Cash Amount: 6.Total Project Cost: $ I a M Lif `t 0 Paid in Full 0 Outstan mg Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) e• � ::2 AS J( tom- License Number Ex irati n Date Name of CSL Holder ��• List CSL Type(see below)'r\���� ` No.and Street Type Description crcl(LY\ QJi t A � /1 v3oll /"YZ Restricted 1&2 Family Dwelling /Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances t(I H 13 t' (m4-{5 Q,Q,QC 5, 0S Cc4,ti, I Insulation Telephone Email address D Demolition 7IRegistere omc Improvement Contractor(HIC) I LI39--iq `.3 r Pcp act ex T HIC Registration Number Expiration Date C Company e or ix Registrant Name (C 5 r 1\r,A ` �1_ i—il! m eiLt �/.SLk`t_ o and Street ( A C'I?��13��a _ mail address{`QI11� City/Town,State,ZIP Telephone 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 Issuance of the building permit. Signed Affidavit Attached? Yes 0 No .0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize ja#2.0 are-iipuk or to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(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 i is plication is true a,.. .:rate to the best of my knowledge and understanding. C.---s (-- ,.., 7poi 4.44 Print Owner' Authorized Agent's Nam Jectronic 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:DO4CE6D2-5089-4402-A456-14A3EC8A2FAA Contract - Detailed Pella Window and Door Showroom of Greenfield 155 Main Street Sales Rep Name: Rousseau, Mitchell Sales Rep Phone: 413-768-8379 Greenfield, MA 01301 Sales Rep Fax: Sales Rep E-Mail: mrousseau@pellasales.com Customer Information Project/Delivery Address Order Information Jessica Morris Morris Jessica 87 Pines Edge Dr Northampton MA Quote Name: Jessica Morris-87 Pines Edge Dr, 87 Pines Edge Dr 87 Pines Edge Dr Order Number: 739Z31R081 NORTHAMPTON,MA 01060-1562 Lot# Quote Number: 18517825 Primary Phone: (413)3207198 Northampton, MA 01060 Order Type: Installed Sales Mobile Phone: County: Payment Terms: C.O.D. Fax Number: Tax Code: MAEXEMPT E-Mail: vassar89@hotmail.com Quoted Date: 8/8/2024 Great Plains#: 56H5855955 Customer Number: 1006897752 Customer Account: 1002355992 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/10/2024 Contract-Detailed Page 1 of 10 Docusign Envelope ID:D04CE6D2-50B9-4402-A456-14A3EC8A2FAA uustorner. Jessica rvrurris rroiect Name: Morris Jessica 87 Pines Edge Dr Northampton MA Order Number: 739Z31R081 Quote Number: 18517825 Line# Location: Attributes 10 Living Room Lifestyle, 2-Wide Double Hung, 58.5 X 55, Without HGP, White Item Price Qty Ext'd Price r rrtt $2,278.92 1 $2,278.92 tr 1: Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 29 1/4 X 55 2172 General Information: No Package.Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock, 1 Lock,White,No Limited Opening Hardware,Order Sash Lift,1 Lift,No Integrated Sensor Viewed From Exterior Screen• Full Screen,White, InView" Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001, Performance Class LC, PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23,Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, 2: Non-Standard SizeNon-Standard Size Double Hung.Equal Frame Size: 29 1/4 X 55 General Information: No Package,Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock, 1 Lock,White,No Limited Opening Hardware,Order Sash Lift, 1 Lift,No Integrated Sensor Screen: Full Screen,White. InViewT" Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001,Performance Class LC. PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23,Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, Vertical Mull 1: FactoryMull,Standard Joining Mullion,Mull Design Pressure-20,Overall Thru Direction-Vertical Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,3 11/16",5", Factory Applied, Pella Recommended Clearance.Perimeter Length= 227". Frame Size:58.5"X 55" For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/10/2024 Contract-Detailed Page 2 of 10 Docusign Envelope ID:DO4CE6D2-50B9-4402-A456-14A3EC8A2FAA uuswrner.Jessica MUMS rrulect game: Morris Jessica 87 Pines Edge Dr Northampton MA Order Number: 739Z3IR081 Quote Number: 18517825 Line# Location: Attributes 15 2F Bed 1 South Lifestyle, 2-Wide Double Hung, 58.5 X 55, Without HGP, White Item Price Qty Ext'd Price r1 $2,278.91 1 $2,278.91 ty 1: Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 29 1/4 X 55 2172 General Information: No Package.Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray 4 Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock,1 Lock,White,No Limited Opening Hardware,Order Sash Lift,1 Lift,No Integrated Sensor Viewed From Exterior Screen: Full Screen,White, InView'" Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001,Performance Class LC,PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23, Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, 2: Non-Standard SizeNon-Standard Size Double Hung. Equal Frame Size: 29 1/4 X 55 General Information: No Package,Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock, 1 Lock,White,No Limited Opening Hardware,Order Sash Lift, 1 Lift,No Integrated Sensor Screen: Full Screen,White,InView' Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001,Performance Class LC,PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23,Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, Vertical Mull 1: FactoryMull,Standard Joining Mullion,Mull Design Pressure-20,Overall Thru Direction-Vertical Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,3 11/16",5",Factory Applied,Pella Recommended Clearance, Perimeter Length= 227". Frame Size:58.5"X 55" For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/10/2024 Contract-Detailed Page 3 of 10 Docusign Envelope ID:DO4CE6D2-50B9-4402-A456-14A3EC8A2FAA Lusturrier. Jessica nnurris rruiect Name: Moms Jessica 87 Pines Edge Dr Northampton MA Order Number: 739Z31R081 Quote Number: 18517825 Line# Location: Attributes 20 2F Bed 2 North Lifestyle, 2-Wide Double Hung, 58.5 X 55, Without HGP, White Item Price Qty Ext'd Price S2,278.91 1 $2,278.91 ITT1:Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 29 1/4 X 55 2172 General Information: No Package.Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray U Q Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior _ Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock, 1 Lock,White,No Limited Opening Hardware,Order Sash Lift,1 Lift,No Integrated Sensor Viewed From Exterior Screen: Full Screen,White,InView'M Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001, Performance Class LC,PG 40,Calculated Positive OP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23,Egress Does not meet typical United States egress.but may comply with local code requirements Grille: No Grille, 2:Non-Standard SizeNon-Standard Size Double Hung, Equal Frame Size: 29 1/4 X 55 General Information: No Package,Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Jambliner Color: Gray Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E NaturalSun+Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock, 1 Lock,White,No Limited Opening Hardware.Order Sash Lift, 1 Lift,No Integrated Sensor Screen: Full Screen,White,InView'M Performance Information: U-Factor 0.26,SHGC 0.51,VLT 0.63,CPD PEL-N-35-00496-00001, Performance Class LC,PG 40,Calculated Positive DP Rating 40,Calculated Negative DP Rating 40,STC 27,OITC 23, Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille. Vertical Mull 1: FactoryMull,Standard Joining Mullion,Mull Design Pressure-20,Overall Thru Direction-Vertical Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,3 11/16",5",Factory Applied,Pella Recommended Clearance,Perimeter Length= 227". Frame Size:58.5"X 55" Line# Location: Attributes 25 Installation Item Price Qty Ext'd Price 54,065.00 1 $4,065.00 FF-7-2 Wide Full Frame Tear Out Installation Qty 3 EXTTRIMI8-Strip and Reuse Vinyl siding w/New J-channel(3 pcs) Qty 3 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/10/2024 Contract-Detailed Page 4 of 10 Docusign Envelope ID:DO4CE6D2-50B9-4402-A456-14A3EC8A2FAA l,usturrler. Jessrcd mums rru)ect Name: Moms Jessica 87 Pines Edge Dr Northampton MA Order Number: 739Z31R081 Quote Number: 18517825 Jessica Morris Mitchell Rousseau Order Totals aed Qame (Please pnnt) i, 41egyRep Name (Please pnnt) Taxable Subtotal 58,655.04 ,,t,SSILa. At,O1MS Akif t u.a retA.SSt ai . Sales Tax @ 0% $0.00 Customer ignature Pe agalespiignature Non-taxable Subtotal $4,285.00 8/11/2024 8/10/2024 Total $12,940.04 pate Signed by: Date Deposit Received $12,940.04 .%.SStca hervlS Amount Due $0.00 'o.L^D -/ ...w 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 8/10/2024 Contract-Detailed Page 10 of 10 Docusign Envelope ID:DO4CE6D2-50B9-4402-A456-14A3EC8A2FAA Pella Products Inc. 4f0 155 Main Street Greenfield, MA 01301 To Whom it may Concern: I Jessica Morris , 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; 87 Pines Edge Dr Northampton, MA, 01060 Please accept this letter in place of my signature on the permit application. Thank you, Signed by Signature: SSiCa NI.OVYiS L401E0DAFA4B1480_. Date: 8/11/2024 _.........41N PELLPRO-01 CHRISTINE ACORO' r DATE(MMIDDIYYYY) `,� CERTIFICATE OF LIABILITY INSURANCE 12/14/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. 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). PRODUCER _CONTACT aCT Christine Sullivan Phillips Insurance Agency,Inc. PHONE 413 594-5984 I FAx 413 592-8499 97 Center Street (ac,No,Est):( ) (A/C,No):( ) Chicopee,MA 01013 Iaa,christlneOphillipslnsurance.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:EMC Insurance Companies 21415 INSURED INSURER B:EMCASCO Insurance Co 21407 Pella Products,Inc INSURER C: 155 Main St INSURER D: Greenfield,MA 01301 - INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LICY EXP Mat TYPE OF INSURANCE AD D SUBRI POLICY NUMBER I NDINVYYjD (MFF �MIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 6A15382 1/1/2024 1/1/2025 P sEs(EaE rrcnr®L $ 500,000 MED EXP(Any one person) $ 10,000 _PERSONAL&ADV INJURY $ 1,000,000 GE AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE 3 2,000,000 Gen X POLICY x mt. LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea accidenNEDt) SINGLE LIMIT $ 1,000,000 X ANY AUTO 6Z15382 1/1/2024 1/1/2025 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNEDf PROPERTY DAMAGE E — AUTOS ONLY I_—. AUTOS ONLY (Per acc,dent I $ A X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LAB CLAIMS-MADE 6J15382 1/1/2024 1/1/2025 AGGREGATE 4,000,000 0ED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X PERATUTE ERµ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YI 6H15382 1/1/2024 1/1/2025 E.L EACH ACCIDENT $ 500,000 FFICER/MEMBER EXCLUDED? N i NIA - 000 (Mandatory n ) E.L DISEASE-EA EMPLOYEE,$ __If yes describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltlonal Remarks Schedule.may be attached if more space is required) Installation Floater$100,000 Included Operations usual to the sale and installation of doors&windows. CERTIFICATE HOLDS CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POUCY PROVISIONS. 212 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents IanOfce of Investigations � J 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/Organizationllndividual): Pella Products, Inc Address: 155 Main st City/State/Zip:Greenfield MA. 01301 Phone#:413-774-7231 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 70 4. ❑ I 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. ® Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p h' 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.❑ 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 Company Policy#or Self-ins. Lic. #:6H 15382 Expiration Date: 1/1/2025 Job Site Address: 87 Pines Edge Dr City/State/Zip:Northampton, MA 01060 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 he ains and penalties jury that the information provided above is true and correct Signature: Date: 8/19/24 Phone#: 413-512-596 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): 1❑Board of Health 20 Bullding Department 31:City/Town Clerk 4.0 Electrical Inspector 51:Plumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts Construction Supervisor iirDivision of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Const cxl1i'st�wvisor CS-096558 ? spires:03/01/2026 TREVOR BRgSS i 10 GEORGE'STREET ,' GREENFIELI MA 01301 2 I>O OI.LYdt10 Failure to possess a current edition of the Massachusetts State Building Codo is cause for revocation of this license. Commissioner , 21,4GG::— Contact OPSI:(617)727-3200 or visit www.mass.govldpl/opsi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington.Street-Suite 710 Boston.Massachusetts 02118 Home ImorovemeritContractor Registration • Type: Supplement Card PELLA PRODUCTS.INC. Registration: 1 155 MAIN STREET Expiration: 0322.2312.2028 GREENFIELD,MA 01301 Jpdate Address and Return Cara. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Rogistration valid for Individual use only before the HOME IMPROVEMENT CONTRACTOR expiration dale. If found return to: TYPE:SupplemCe' �r.;. ar Card Office of Consumer Atfajs.and9usiness Regulation naru 3egis1tatlon rntLen 1000 WashinglonrSt l -Suite 710 142279 01'27;2023 Boston.MA 0215 % f PELLA PRODUCTS.INC. C 1 TREVOR GROSS 155 NNN STREET GREENFIELD.MA 0130, Undersecretary iid-latthout signature City of Northampton c N ti`, c��s............SIC Massachusetts ' ' !� i • `; t % 7 DEPARTMENT OF BUILDING INSPECTIONS ? j ; 212 Main Street • Municipal Building J6 ps Northampton, MA 01060 sb ;..k3‘10 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 165 ((,(U (11/1:040a(CI ( J./,a- (i(&/ The debris will be transported by: Name of Hauler: Signature of Applicant: Date: <tr-i / -(/