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38B-145 BERKSHIRE INS Fax:14135684284 Aug 6 2010 8:11 P.01 ACORD_ CERTIFICATE OF LIABILITY INSURANCE 18 /6/ O ) PRODUCER (413) 773 -9913 FAX: (413) 774 -3872 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MaBr30ue IiYSttranGe Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE . y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 117 Main Str ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 638 Greenfield NA 01302 -0638 _ INSURERS AFFORDING COVERAGE ' N INSURED INSURER Continent western • Pella Products, Inc. INSURERS' ATTN: Doha Benjamin INSURER C; 155 Main Street INSURER D: Greenfield MA 01301 -3258 INSURER E: ;,OVERAGES THE POLICIES or INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NO1V 1Tt(STANDING 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. ,AG1113PS;' TE l IMITS SHOWN MAY HAVE BEEN RF,DUCED RY PAID CLAIMS. INSR ABI•L POLICY EFFECTIVE POLICY EXPIRATION I T$,INR - • TYPE OF INSURANCE _ NUMBER DATE (MMIDDKY) DATE (MM/DOKY) _ LIMITS GENERAL LIABILITY Farm or.0,(JRRFN $ 1,000,000 X COMMERCIAL GENERAL. UAS141TY DAMAGE TO RENTED 300,000 - S (Ea c1Fc a $ _ A 1111■ CLAIMS MADE I X OCCUR CPA020470113 1/1/2010 1/1/2011 MEDEXP (Any Oneperson) $ 15,000 PEREONALR Any INJURY $ 1,000,000 MI GENERAL AGGREGATE S 2,000,000 GEr4L AGGREGATE LIMIT APPLIESPER: PRIIlIUCTS - COMP /OPAGG 5 2,000,000 © POLICY fPIFCT El LOC _ AUTOMOBILELIABRITY COMBINED,SINGLE LIMB $ 1,000,000 w ANY AUT accident) .. . (Ea accident) A III ALL OWNED MAA020470213 1/1/2010 1/1/2011 BODILY INJURY H SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY 9 (Per accident) X NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) • GARAGE (ABILITY . AUTO ONLY - EA ACCIDENT $ I II ANY AUTO OTHER THAN EA ACC $ AUTO ONLY; p44 S EXCF.88NMBRELLA LIABILITY FACH OCCURRFij:F $ OCCUR ( CLAIMS MADE AGGREGATE S 1_ . DEDUCTIBLE $ RFTENTICN, $ . y, � $ A WORKERS COMPENSATION AND $ T OR IAA A ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECIJTIVE E.L. EACH ACCIbNT $ 500,000 OFFICER/MEMSER EXCLUDED? wCA020470513 1/1/2010 1/1/2011 E.L DISEASE - EAEMPLOYEE5 500,000 IT yes, describe under SPECIAL PROVISIgInt below _ E.L DISEASE - POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONENEHICLESIEXOWBION$ ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations usual to the sales of windows & doors. CERTIFICATE HOLDER CANCELLATION (413) 736- 3390 SHOYLB ANY OF THE ABOVE WOMBED POLICIES BE CANCELLED EEPORE THE City of Northampton EXPIRATION DATE THEREOF, THE ISSUINO INSURER WILL ENDEAVOR TO MAIL 212 Main Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Northampton, NA 010 60 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION DR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �� Norma Laforest /SPG ACORD 25 (2001108) 0ACORD CORPORATION 1988 INS025 010).058 Page l of 2 • 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): /F / / cY O Cf U o �j i "7 6. Address: / 1 cV'r2 S / /55- /1 r r•e City /State /Zip: F<� � f I C� t" d /°' //? 0/80/ Phone #: %f /J - Are you an employer? Check the appropriate box: Type of project (required): I. [ I am a employer with 7() 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 working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t 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._1 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. XI Other r /c're /14 Wow) comp. insurance required.] eVelci 1)0o r 5 *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' 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: /� /( c7CY ! c 7 n S G! r c7 r? ce r n Policy # or Self -ins. Lic. #: (i(/ 1 I 4.20 7057 .3 Expiration Date: /- f r; Job Site Address: C0100(\kjLJ R\le)(13 City /State /Zip: k pbp 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 certi under the pains and pe allies of perjury that the information provided above is true and correct. Si•nature: ilk,. �`1 — Date: ' cD. 0 Phone #: C `1 13�, 92 X l i b 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 #: ce ..._„,,,._.... , _, ..., . de .0 1 4 - if 4 0 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 • Boston, MasswIlusetts 02116 ,..., . .,.., . , Home Improvement ',,, ei ....ctor Registration Registration: 142279 , 7 , Type: Private Corporation P r----- -- - - -7-:rJ-1= - 1 r Expiration: 3/24/2012 Tr# 294515 ----= - - =.7 :-,-, PELLA PRODUCTS, INC. gl . _-:-1,,...‘,f . , 1 7 - , :. --' - ' 7 ' 7 ", -- 1 , ''''':::::-- -4 l ', 4 GARY SHERMAN 155 MAIN STREET .....=t-.... / ...-.:.... - - . ', GREENFIELD, MA 01301 "k; .'; \ -. Update Address and return card. Mark reason for change. Fl Address 11 Renewal L Employment — I Lost Card DPS-CA1 0 5014-04/04-0101216 gi eoingricLA.weald of..../gAidaduezei6 . Office of Consumer Affairs & Business Regulation License or registration valid for individui use only HOME lMPROMEMENT CONTRACTOR before the expiration date. If found return to • I !.. 74.4111 . 4-4 * • - Registratio442279 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 51'70 „,,,,.— .,z- Exp I ratORIP-3/2112 Tr# 24515 ...-0 9 Boston, MA 02116 Type ',2 c ticietitb* f oietio n • i :4,..,,:i PELLA PRODUO GARY SHERMAVUM-- 1.% .417 / / 155 MAIN STREET,'‘-?;- .,...' €..../.-pd53.5,_ _ . e , . Al _ 4. GREENFIELD, MA 01'3a1.2- ' Undersecretary ot valiy MO' signature ... ' 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. , u t n.4 r1 0t ,0 r t 4 *tifotiatyl 4* r = n �- : F .mot ,-.‘, , `�^'.-� a .f� hiact RtitiBP I Erik } -' ' t :. Ex .. crtr WV Coo [' +% :: Tif - off To Whom It May Concern: a e— I � �° , as property owner, give permission to our contractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in may home, located at l �N ? Cfl/ LP7 S � . Please acceiit this letter in place of my signature on the permit application. Thank you, 4/(100■11) atsucy Please Print Name 4 / // / ////////, . • fb Homeowner's S atu • - Date 8.1 Licensed Construction Supervisor:. Not Applicable ❑ Name of License Holder : 0..)1.0%. O ,- License Number Mc4i\ eex C- tot-G 3A, r y- #i v t t i Address Expiration Date , OrbAl C Signature Telephone Lt33l ?E <€t `6i Sas�sa tai ®7 Not Applicable ❑ PQ\CC rndvckS _ly221 Company Name . Registration Number 155NAuAh d es -. e ex fi.e r 0 r �o 31au ) 0- Address 1 Expiration Date Telephone (Lk 1�j,2 a 3 ' g �t�' 'li?� *•e 'y �� ,tri: ur �'S.� t'3.°':.'c''�"'.2.�.^_�:J., .. ,?3 ..s. .v_,?f.� v;:.w. k'"_`.cfi _ € .Yay��a.�� &� ^h.aY'�... rte` �4::: 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 ❑ The current exemption for "homeowners" was extended to include Owner occupied Dwellinzs 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 . „ 4 �. • New House ❑ Addition ❑ Replacement Wi ,dows Alteration(s) [] Roofing LI Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding [O] Other [D] Brief D- cription of Proposed Work: Z. ' • .. I •. $ r �L _ wa) �� . /. it • 4 - .� • • CQ QC, COL,. �► n01 j S--\\005 S--\\005 � Alteration of existin` dedroom / Yes V No Adding new bedroom Yes V No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet t F r ^IFS aY r ' a "erne `a © ' 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. k) 1 A 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 Cilk pn 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 �w'� m+�+n`%.�*A^'4'•�AY�K� 3Y• �...f Std � N W - i 4 ^'Wfi2i < e¢ i 1s �w3K —�� T,3 ;�,:F'k � ffi 'Sk 4 1 v1 n 4 . i h%rl r , as Owner of the subject property hereby authorize ?Q \C.. ?cz::) , c -. \nL to act on my behalf, in all matters relative to work authorised by this building permit application. LSPo S o r.o d c'nn\ [CCr*- QWAel e.Q) 1 )a l l I o Signature of Owner" Date I, 4.. 'Ca ! ®C _ _ , as Owner /Authorized Agent ereby rieclare that the statement and information on the foregoing app ication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name ' (� t 10 9 Si rra'f6re oYOwntr /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 1 I I 11 1 Frontage I 11 I 1 1 Setbacks Front 1 I 1 .1 1 1 Side L:1 1 R:[. 1 L:I 1 R:1 I 1 1 1 1 Rear I 1 I 1 . 1. 1 Building Height I I 1 1 I I Bldg. Square Footage 1 1 1 1 °"° 1 1 1 I 1 1 Open Space Footage I I I I I I I 1 ( I (Lot area minus bldg & paved parking) # of Parking Spaces 1 1 1 I 1 I Fill: (volume & Location) 1 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW )8) YES 0 IF YES, date issued:I IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES IF YES: enter Book I Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 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 0 NO IF YES, describe size, type and location: ,,,j D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (X) IF YES, describe slze,type and location: E. Will the construction activity disturb (clearing, grading, vation, 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. 29 COLUMBUS AVE ` BP-2011-0274 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2011 -0274 Project # JS- 2011- 000456 Est. Cost: $10870.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 6011.28 Owner: RISLEY JOHN T & ALEXANDRA C RISLEY SCHROEDER Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 29 COLUMBUS AVE Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:9/23/2010 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 9/23/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner