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23D-155 (2) . SITE RESPONSIBILITIES Customer: David Jackson Date: 03/18/2010 Order #: Signature: Paul Picard Signature: ��"..r..m ■ .► 1 50% Deposit required at time of order. 2 Final payment is to be made to installation team on the morning of the last day of installation. 3 If 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 Due to inclement weather or site conditions, it may be necessary to reschedule. 6 We cannot and will not guarantee specific dates or days of the week for installation. 7 Time given to complete a job is an estimate, extension of time is possible 8 An Install appointment will be confirmed at Verification. A courtesy reminder call will be placed 1 week prior. 9 Unforeseen rot repair will be quoted on site as additional work via a Change Order. 10 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 affect the status of a project from being Substantially Complete. 11 In the event that any products are unable to be installed, the final payment will be recalculated. The cost of 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. 12 Order is not binding until approved by Pella Products management 13 Pella wi(Ftre all necessary Building Permits Type of Installation: New Construction: (tear out installation) 1 x 1 Completely remove interior and exterior Trim, completely remove existing window frame, install new window in rough opening, re -trim both interior and exterior of window/door. Pocket Install : (sash replacement, existing frame remains) 1 x Remove interior or exterior stops, install new window in existing window frame opening, re -use existing or replace window stops (interior or exterior) Some glass loss will occur. Lead Paint Discloser: # 1 Home was built prior to 1978, Lead Paint discloser has been signed and "Protecting Your Family From Lead in Your Home" brochure has been given to Home Owner #21 + Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will x Authorized to install Yard Sign on 1st day of installation and remove 7 days afterward y x Era sse someone vies age 18 is present at all tiles while Peµa employees ale . irt the home. x ( I Deliver and unload products x 1 1 Place drop cloths in work areas t f n Remove & reinstall interior and exterior trim if applicable x 1 1 Remove & reinstall existing shutters and awnings by contract x 1 1 Remove existing product and adjust or modify opening as needed For all service needs, 5 Provide*all equipment necessary to install products please call: 3001 957 - 3552 x ( Cut all wood and other materials outside of home Please make sure you x 1 J 1 Install all products purchased mention that your project x I ( ( Insulate and caulk around products was installed by Pella and reference your order x I Remove stickers and perform initial cleaning of all glass surfaces number x I I Demonstrate proper operation of products x I Confirm that all products are in working order x Remove drop cloths, vacuum and remove all old products from premises © 1 Finish (paint or stain) product purchased 1 f x ( Cut -back or tie trees, bushes, shrubs from exterior wall n IT] ] Arrange to have alarm system disconnected and reconnected n x 1 Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor y x y Remove and reinstall existing window treatments, wait\ hangings and air conditioning units. x J Remove and reposition furniture in work area 1 1 1 x 1 Secure pets in a safe manner x Remove valuable / breakable items from work area x Remove snow from area of worksite if necessary Custpmer: Project Name: Jackson David 152 Maplewood Ter Florence MA Order Number: 739 Quote Number: TBD listed. Pella Products Inc. management has final authority on acceptance of this order. Your signature confirms the accuracy of the product(s) chosen. Pella Products assumes no responsibility for accuracy of take offs from drawings or blueprints or that the products listed will be sufficient to complete customers intended project. The Buyer agrees that the product(s) listed herein are correct, final and cannot be changed, returned or canceled. Deposits are partial payment of the contract and are not refundable. The Buyer agrees that if paying by credit card that authorization is granted to the seller to debit the Buyers credit card by signing this contract. The Buyer agrees that payment discounts do not apply when paying with a credit card. A 1 -1 /2% SERVICE CHARGE per month (18% PER ANNUM) will be added to all outstanding balance past our stated terms, plus lawyer and account fees for collecting outstanding accounts. The Buyer agrees that the customer delivery date is a realistic estimate of when the product is to be delivered. Items remaining in our warehouse for more than 30 days beyond the agreed to delivery time will be subject to a storage and handling fee of 1% of the net amount of the order ($25.00 minimum charge). The Buyer agrees that the product can be delivered without the Buyer present and agrees to accept the shipping documents as proof of delivery. The Buyer agrees not to hold the Seller responsible for any damage to driveways, sidewalks, trees and overhead wires caused by the Seller's delivery vehicles. The Buyer agrees to examine the product(s) upon delivery and within 7 DAYS OF DELIVERY provide the Seller notice of any discrepancy between the product(s) ordered and the products(s) delivered, including hardware. If the Buyer does not provide notice within 7 days the Buyer accepts the product(s) as is. ❑ Project Checklist has been reviewed Order Totals Taxable Subtotal $5,537.51 Credit Card Approval Signature Sales Tax @ 6.25% $346.09 J Non - taxable Subtotal $1,587.00 JA J �'r t r Total $7,470.60 Customer Name (Please print) Pella - - - - . Name (Please print) Deposit Received '!' Amount Due $7,470.60 Customer Signatu Pella Sales Rep Signature Date Date For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com Drin+o,r „n nl/1 0i1n1 n rnnfrnnf _ no+nao,+ Dn„o 1 „f 1 Customer: David Jackson Quote Description: 739 Architect Slider Order Number. 739J3DP051 Line # Quote Qty PO Qty Description Item Price Ext'd Price 45 0 1 OBLT5000 - Keylock, Brass, Keyed Alike List Price: $18.74 Location: None Assigned Rough Opening: Discount % = 0.00 % Frame Size: Discount $ $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Pella Catalog Net Price: $18.74 $0.00 Last Revision Date: Order Pricing Totals Total List Price $7,342.45 Discountable Amount $9,715.45 Discount 2.990% $219.50 Non - Discountable Amount ($2,373.00) Net Before Payment Discount $7,122.95 Payment Discount Amount $0.00 Net After Payment Discount $7,122.95 Taxable Subtotal $5,562.42 Sales Tax 6.25% $347.65 Non- taxable Subtotal $1,560.53 Total (Total Net + Taxes) $7,470.60 Deposit Received $3,735.30 Amount Due $3,735.30 Printed on 04/14/2010 Office Order Copy Page 5 of 5 Customer. David Jackson Quote Description: 739 Architect Slider Order Number. 739J3DP051 Line # Quote Qty PO Qty Description Item Price Ext'd Price 30 1 0 Exterior Trim: Brown aluminum wrap List Price: $0.00 Location: Rough Opening: 0" X 0" Discount % = Frame Size: Discount $ $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: $0.00 $0.00 Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 35 1 0 Spring Promotion 25% off product List Price: ($1,845.00) Location: Rough Opening: 0" X 0" Discount % = Frame Size: Discount $ $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($1,845.00) (51,845.00) Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 40 1 0 Spring Promotion 25% off install List Price: ($528.00) Location: Rough Opening: 0" X 0" Discount % _ Frame Size: Discount $ $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($528.00) ($528.00) Last Revision Date: Printed on 04/14/2010 Office Order Copy Page 4 of 5 Qustomer. David Jackson Quote Description: 739 Architect Slider Order Number 739J3DP051 Line # Quote Qty PO Qty Description Item Price Ext'd Price 20 2 2 2-Step Colonial 2.5 ", Length: 144, Early American Stain List Price: $51.24 Location: None Assigned L� �. - Rough Opening: 1: 2-Step Colonial 2.5" Discount % = 0.00 % Length: 144lnterior Color / Finish: Early American Stain Discount $ $0.00 $0.00 Frame Size: 0" X 0" Final Wall Depth: Frame Perimeter (inches): Assembly Type: Pella Assembled Net Price: $51.24 $102.48 Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 22 2 2 2 -Step Colonial 2,5 ", Length: 96, Early American Stain List Price: $32.92 Location: None Assigned Rough Opening: 1: 2-Step Colonial 2.5" Discount % = 0.00 % Length: 96lnterior Color / Finish: Early American Stain Discount $ $0.00 $0.00 _,. Frame Size: 0" X 0" Final Wall Depth: Frame Perimeter (inches): Assembly Type: Pella Assembled Net Price: $32.92 $65.84 Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 25 1 0 Interior Trim: 21/2 Colonial from factory List Price: $0.00 Location: Rough Opening: 0" X 0" Discount % _ Frame Size: Discount $ $0.00 $0.00 Final WaII Depth: . Frame Perimeter (inches): Assembly Type: Manual Line Net Price: $0.00 $000 Last Revision Date: Printed on 04/14/2010 Office Order Copy Page 3 of 5 Customer David Jackson Quote Description: 739 Architect Slider Order Number. 739J3DP051 Outside View Line # Quote Qty PO Qty Description Item Price Ext'd Price 10 1 1 Architect, Sliding French Door Fixed / Vent / Fixed, 140.25 X List Price: $9,407.05 81.5, Brown, 6 -9/16" L Rough tio Opening : 141.25" X 82" 1: Non-Standard Size Fixed / Vent / Fixed Sliding French Door Discount % = 2.33 % Frame Size: 140.25" X 81.5" Frame Size: 140 1/4 X 81 1/2 Discount $ ($219.50) ($219.50) General Information: Standard, Clad, Pine ' — " r" — Final Wall Depth: 6 -9/16" Exterior Color / Finish: Standard EnduraClad, Brown 444 Interior Color / Finish: Early American Stain Interior Frame Perimeter (inches): Glass: Insulated Tempered Low E Advanced Argon Gas Assembly Type: Pella Assembled Hardware Options: Brown, Handle Included, Handle Included, Brown price: $9,187.55 $9,187.55 Net Last Revision Date: Screen: Sliding Screen, Wood Interior / Brown Exterior, InView Grille: Wrapping Information: Foldout Fins, Factory Applied, 6 -9/16" Factory Applied, Perimeter Length = 444 ", Glazing Pressure = 205. PD -3 - 3-Wide Patio Door Install Qty 1 PD-6 - PD Exterior Aluminum Capping (Coil Qty 1 Stock) Line # Quote Qty PO Qty Description Item Price Ext'd Price 15 1 0 INSTALLATION - INSTALLATION List Price: $140.08 Location: None Assigned Rough Opening: Discount % = 0.00 % Frame Size: Discount $ $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Branch Catalog Net Price: $140.08 $140.08 Last Revision Date: Customer Notes: Permit Fee Printed on 04/14/2010 Office Order Copy Page 2 of 5 "R;( Office Order Copy 7,0 Branch Number: 73900 Order Number: 739J3DP051 Window Store Name: Quote Number: 1374087 Quote Description: 739 Architect Slider Project Name: Jackson David 152 Maplewood Ter Florence MA Customer Information Deliver To Address Order Information David Jackson Lot # Sales Rep Name: Picard, Paul Cust Delivery Date: 04/26/2010 Address: Business Segment Retail Quoted Date: 03/19/2010 152 Maplewood Ter 152 Maplewood Ter Market Segment: Single Family Replacement Contract Date: 03/26/2010 Order Type: Installed Sales Booked Date: 03/26/2010 Effective Discount: 2.990% Earliest LRD: 03/31/2010 FLORENCE, MA 01062 FLORENCE, MA 01062 Commission Split: Picard, Paul - 100% Contact Name: County: HAMPSHIRE Tax Code: MASS Tax Exempt #: Payment Terms: Deposit/C.O. D. Customer PO #: Day Phone: (413) 5846733 Owner Name: Accessories Managed Accessory Delivery Date Mobile Phone: David Jackson Fax Number: E -Mail: Owner Phone: (413) 584 -6733 Great Plains #: 53H5846733 Customer Number: 4054963 Delivery Instructions: 91s to exit 20 Northampton. Tum right at 1st light, then left at next light on to Jackson Street. At stop sign go straight, then next stop tum right and then a quick left on Elm Street. Tum left on Hinckley Street then right on Maplewood Ter. House/Drive on right sign says "Jackson Lane Private Drive ". Installation Notes: 91s to exit 20 Northampton. Tum right at 1st light, then left at next light on to Jackson Street. At stop sign go straight, then next stop tum right and then a quick left on Elm Street. Tum left on Hinckley Street then right on Maplewood Ter. House/Drive on right sign says "Jackson Lane Private Drive ". Printed on 04/14/2010 Office Order Copy Page 1 of 5 ?li -6 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Registration: 142279 Type: Private Corporation Expiration: 3/24/2012 Tr# 294515 PELLA PRODUCTS, INC. GARY SHERMAN 155 MAIN STREET GREENFIELD, MA 01301 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card JPS CA1 * 50M- / �!!,,// - 11:4e fcan�ar oneve,ajb n! . 71cr, Jacctijel s Office of C onsumer Affairs & Rosiness Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 142279 1-4r 10 Park Plaza - Suite 5170 Expiration: 3/24/2012 Tr# 294515 Boston, MA 02116 Type: Private Corporation PELLA PRODUCTS, INC. GARY SHERMAN / / 155 MAIN STREETu -- �� -- 4 GREENFIELD, MA 01301 Undersecretary A / ot vali itho 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. .1 tilt r r t} p : rlrrr ni •1 uE'r 4ai 1 RItgrldr. -d fa: r.4 i 1 11i r f trl rU a mil i siurrr.l: .. _,_ttc_r . _ u f CO tOirtstri t4 r .14-at; ft: - 1 x Family [Winn: FF?r..x rr r• 1 1:.: 0 OAL "O C WHITE 1 CARPENTER ;T Fhlu p ire to nssAN% c current editir n r31 the Mil.itchtts trg `ttAtif Cush: ORANGE, M" 0 334 # fi i3 tmth.i° For . +ernCat an of this lieenu. Rcf'crtn: WWW_?ktisa.GtA!D'S 1,°1-12L1 • Jan 14 10 02:23p Accounting Dept 1,413,773 -3740 P• .3/4'- 7` 3 !l The Commonwealth of Massachusetts Department of Industrial Accidents 1. lit Office of Investigations =7:1151.....= - 600 Washington Street - ; tom ' .�. Boston, MA 02111 4 r4 "ztn www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organizationllndividual): %� f � � Address: / .� /1 eq i h V ic City; /State /tip: C ,,rr non . /V 4 4 Phone #: 2- 7702- (2 /6 Are you an employer? Check the appro,riate box: . Type of project (required): 1. 1 am a employer with 70 4. ❑ I am a general contractor and 1 6. ❑New construction employees (full and/or part- time).* have hired the sub - contractors 2 . ❑ 1 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. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ W e are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per NIGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no , ,,i employees. ['No workers' 13.X Other /liC�feV« Gf/l comp. insurance required.] rid (loo r ^ s *Any applicant that checks box #1 must also 611 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 oldie 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 Mat is providing workers' compensation insurance for my employees. Below is the policy and job site information. f / Insurance Company Name: /"7 ce'Clt /,7 �rr u r ,mn ce Cley r7 l/ Policy # or Self -ins. Lic. #: a r c/4 ad ei / 7,2 5" /J Expiration Date: t/— Vie r 2 0 / / Job Site Address: 151 Myp'ewCOd. 1C(CC I_9- Cit /State /Zip: y�f Y,+,fC', 4 A__01062.- 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 5250,00 a day against the violator.. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DLA for insurance, coverage verification. Ida hereby ce.' u , er the pains and penalties of perjury that the information provided ab is true and correct S:_tra e: i . _ a.+t, d' .' a 4 . III • e: 1.J fw 9 2 Official use only. Do not write in this area, to be completed by city or town ojf ciaL City or Town: Permit/License # __, - Issuing Authority (circle one): I. Board of Ilealth 2, Building Department 3. City/Town Cleric 4, Electrical Xlnspector 5. r lumbing Inspector 6. Other Contact Person: Phone #: • FROM BerI< hire Insurance Group (TMU)RPR 15 2010 11:00/57.10:57/14..7527018025 P 5 • 1 ACORD r „ CERTIFICATE OF LIABILITY INSURANCE 4/15/20 0 PRODUCER (413) 773 -9913 FAX: (413) 774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MassOne Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE g Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 638 Greenfield MA 01302 -0638 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental Western Pella Products, Inc. INSURERS: ATTN: John Benjamin INSURER C: 155 Main Street INSURER D: Greenfield MA 01301 -3258 INSURER E: • COVERAGES 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, e THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES., r AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS _ INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS L • TR JNSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM /DDIYY) DATE (MMfDD/YY) - GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00o, X COMMERCIAL GENERAL LIABILITY PREM SES( aEo $ 300, 0 0.0 A CLAIMS MADE X OCCUR CPA020470113 1/1/2010 1/1/2011 MED EXP (Any one person) S 15,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 — GE�N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - CQMP /OP AGG $ 2,000,000 'J POLICY Te-F - I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1, 000, -000: ANY AUTO (Eaacadent) A ALL OWNED AUTOS MAA020470213 1/1/2010 1/1/2011 BODILY INJURY (Per person) $ X SCHEDULED AUTOS _ X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ - i;_: ANY AUTO OTHER THAN EA ACC $ _. AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ - -- OCCUR I 1 CLAIMS MADE AGGREGATE $ .. $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND X _TORY LIMITS LIMITS EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500,00P ANY PROPRIETORJPARTNERJEXECUTIVE OFFICER/MEMBEREXCLUDED? WCA020470513 1/1/2010 1/1/2011 500,000 E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below 500 ,0 _ , E.L DISEASE POLICY LIMI -$ - OTHER DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Operations usual to the sales of windows & doors. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEi - � { David Jackson EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 152 Maplewood Terrace 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT..., Florence, MA 01062 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE . INSURER, ITS AGENTS OR REPRESENTATIVES. . AUTHORIZED REPRESENTATIVE , - Robin Sargent /RMS ACORD 25 (2001108) O ACORD CORPORATION 1988 INS025 (0108).OBa Page;raf.I{ 7. PELLA PRODUCTS INC 155 MAIN STREET GREENFIELD, MA 01301 �ln tli(. iCScsU) /5 2 M aple o3 Oat le -rraLP t orevsCe � W1,4 0I062____ Subject: Disposal of Debris The purpose of this letter is to certify that all the debris resulting from any project undertaken by Pella Products Inc. in your Town will be transported to a dumpster at our main facility at 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. John P. Benjamin Accounting Manager { SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \\,, Not Applicable ❑ Name of License Holder : �f1t.1 t i. LAV,, \ l e_ 0 q/ f?‘ License Number !SS Men <S 'ee - Green i ei.61.. lUA 0t301 13/ 201/ Address 1 Expiration Date Q):14Q 9 C ik) , �/l eJ 772 - 01S3 Sin ure Tele hon 9. Registered Home Improvement Contractor: Not Applicable ❑ P dI0. Prod, is TVA. c. 1 Company Name Registration Number /SS 1 , S-Ye e. Greer) n e ed /IAA D 13 d l 2 5t - z 0 / z-. Address';, 1 Expiration Date 0 C. ( k r d9.. Telephone — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affida it must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil ng permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption 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 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 • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Q Replacement rndows Alteration(s) Roofing LJ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[l Siding [0] Other [0] Brief Description of A T rin Proposed 't r ,, r 5 Work: , s+al�a� o 3 '(Aide all Donr. US in f�c i$'tf"rJq () ;a N . 0 - Irv& luzi Alteration of existing bedroom Yes No Adding new bedroom Yes No �J G �� J ' 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 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. 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. 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 SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT d ( � � QC V�SQ,f') , as Owner of the subject property hereby authorize ,pC t 1A Tf 0c1)C.46 , roc. . to act on my behalf, in all matters relative to work author by this building permit application. yk _See Zig ncd MhcE Y•!Q•l Signature of Owner J Date 'G 1k 'rOJCJC k r J. n C . , as Owner /Authorized Agent hereby 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. t Print N e n Signature of 00,4r/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 m 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 ping) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® 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 DONT KNOW 0 YES l 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 ® 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 ® 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only • City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability APE - Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Site Plans L_..._._ Other Specify -- .APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 PropertYAddress: This section to be completed by office 1S2, Mar le.t.00d Terrace Map Lot Unit FI cri .nce / MA 0 10 62. Zone Overlay District EIm St. District CB District SECTION 2 - PROPERTY OVyNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1�, at1a - 3'ackson 152 Rap/ewoocI 7er Name (Print) Curre Maling Add s : J 4 /.9 SR I - 6 733 ',Sew ,51QI�eQ cm fra F Telephone Signature 2.2 Authorized Auent: D a i d ( j I e / S S i t i a.i r1 ,.11 , Green e ld 1 0 (30 witi) Name (Pri Current Mailing Address: C � 1&J (1 13 77 Z -0 153 Signature Telepho SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Li 70 ! 0 (a) Building Permit Fee 00 2. Electrical (b) Estimated Total Cost of L Construction from a > [ T -t (0 • b 0 • 3. Plumbing o Building Permit Fee �� 4. Mechanical (HVAC) 7,6 6 0 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) — 7 / 470 • () Check Number 0 3 4 6. 9? This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 1a my ft2Pttw BP- 2010 -0959 GIS #: COMMONWEALTH OF MASSACHUSETTS : 23D',- 155 1 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- 2010 -0959 Project # JS- 2010- 001421 Est. Cost: $7470.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 102801.60 Owner: JACKSON PATRICIA E Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 152 MAPLEWOOD TER Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:4/29/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE SLIDING DOOR 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 4/29/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo