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25C-071
BERKSHIRE INS ' Fax:14135684284 Jun 21 2010 9:03 P.03 ACORD,,, CERTIFICATE OF LIABILITY INSURANCE 1 DATE 2��2 0 PRODUCER (413) 773 -9913 FAX: (413) 774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MassOne Insurance Agency 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. INSURER B: ATTN: John Benjamin INSURER C: . 155 Main Street LNSURERO; Greenfield MA 01301 -3258 INSURERS 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. AGGREG6JF I IMIYS SHOWN MAY HAVE BEEN REDI II :FIT RY PAID f A AIMS. INSR AOWL POLICY EFFECTIVE POLICY EXPIRATION I TJNSRD TYPE OF INSURANCE _ POLICY NUMBER DATE IMM/DD(YY) DATE (YMND/W) LINTS GENERAL LIABILITY EACH OCCURRENCE .F 1, 000, 0 0 0 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY 300, 000 PREMISES (Ea titan' S A I CLAUASL4AOE I X I OCCuR CPA0204701.13 1/1/2010 1/1/2011 MEDEXP (Any oneperson, $ 15, 000 — PFRSQNAI &ply INJI MY ,$ 1,000,000 _ GENERAL ACOIj C,Tg S 2,000,000 GEN•L AGGREGATE LIMIT APPLIES PER: PRODUCT A(3(, $ 2,000,000 � �I POLICY JEC�T n LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Eaarrident) $ 1.000.000 A ALL OWNED AUTOS MAA020470213 1/1/2010 1/1/2011 BOOILY INJURY X SCHEDULED afros (Per person) S X HIRED AUTOS BODILY INJURY S X NON -OWNED AUTOS (Per acddelrt) PROPERTY DAMAGE S • (Per acd Lent) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ 1 ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESS WISRELLA LIABILITY EACH OCCURRENCE S — I OCCUR u CLAIMS MADE AGGSFGATE $ S DEDUCTIBLE S RETENTION S $ A WORKERS COMPENSATION AND X TORY LIkaR 1 I FF EMPLOYERS LIABILITY 500,000 ANY PROPRIETOR/PAR TNERIE](ECl1TNE EL. EACH ACCIDENT $ OFRGER/MEMBEREXCLUDED? yWCA0204705,.3 1/1/2010 1/1/2011 EL, DISEASE - EA EMPLOYEE $_ 500,000 If yes, describe under SPECL'Q PROVISIONSSNow F,.L,. DISEASE - POLICY 5 500,000 OTHER DESCRIPTION OF OPERATIONSI10CA1I0NSNBIICLEBIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations usual to the sales o1r windows &' CERTIFICATE HOLDER _ CANCELLATION (413) 736 - 3390 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Danie11e Kahn EXPIRATION DATE THEREOF, THIS ISSUING INSURER 1MLL ENDEAVOR TO MAIL 42 Day Ave. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Northampton, MA 01060 FAILURE TO 00 SO SHALL 'POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. . AUTHORIZED REPRESENTATIVE Norma. Laforest /SPG o_ ACORD 25 (2001/08) © ACORD CORPORATION 1988 ,...- . ,.. Page 1 01 2 Ar The Commonwealth of Massachusetts ._.... Department of Industrial Accidents fit � i. Office of Investigations i,kka„ l° , 4 600 Washington Street . },, Boston, MA 02111 •,.�Y� ` www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly J Name ( Business /Organization/Individual): //'/ / � e �j 1 "2 C. - Address: /53 / % iir) S 9r(e City /State /Zip: 6 ref) 7 f /d /VI U /30 / Phone #: "//J - 770 v / 3 Are you an employer? Check the appropriate box: Type of project (required): 1. (] I am a employer with 7() 4. ❑ I am a general contractor and I / 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y P h 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ 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.E 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.Cg Other,/,4V« l�/2,. dew) comp. insurance required.] 1 .L)ao r 5 *My 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: /� /( c CI / / n S u r c7 r1 CC i 4, n Policy # or Self -ins. Lic. #: (.1) G k9 v7 a 7 7057 3 Expiration Date: () /- 0 7 0 // Job Site Address: i2- b ,/ I J lUe___ City /State /Zip:��Y p 01,0(p0 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 t 1 ains i ndpenalties of perjury that the information provided above is true and correct. Si. nature: / l • 1 , • � • � ' '1 Date: � I 2 ) ((� Phone #: 0-11 3, 73 � 10 1 � � 3 � 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 #: g2 e e, - ro ,,, 01 or 4 4 of . 4 ' 4 0 r 4 'Z.7:—"= f i Office of Consumer Affairs and usiness Regulation _ _ 10 Part Plaza - Suite 5170 % �= 0, Boston, Mass usetts 02116 . Home Improvement 1)I '1 ctor Registration _ 1 : _ Registration: 142279 � (7 � � � � 1 , 7 _ Type: Private Corporation 7 =, 1.I 4 . w x Expiration: 3/24/2012 Tr# 294515 PELLA PRODUCTS, INC. "„ GARY SHERMAN " ` , — � 155 MAIN STREET a -s) GREENFIELD, MA 01301 _�. z , . ...LL -f ; c. �f., r i, -. _ 11 Update Address and return card. Mark reason for change. E Address [] Renewal Employment – I Lost Card DPS -CA1 0 50M- 04104.3101216 glze €am w-iter eaitA. el,/gacticzedia3e41 ,: License or registration valid for individul use only it � — da Office of Consumer Affairs & Business Regulation before the expiration date. If found return to: i 5 HOME IMPR YEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation 1 - Re istration 44227 w ��= �_ , � 9 10 Park Plaza -Suite 5270 t Ex pirat iy / s » �' r r 2012 Tr# 294515 � , Boston, MA 02116 Type :1s I C ate Corpo ation r = PELLA PRODUCT I: + . t;;l GARY SHERMA : . r , t- ; 155 MAIN STREET, c -6;.„.:1 € f / GREENFIELD, MA 013O"1 Undersecretar of vaR/ 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. s tse i ment 04POtio t Lttmstd ,o, i 2r *ea* �. ► - rte:: sr: Vtfe To Whom It May Concern: I, j>r At,"cit A hi% , as property owner, give permission to our contractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in my home, located at 12. A Avenue . Please accept this letter in place of my signature on the permit application. Thank you, . AM l t/ xx._., , Please Prin N .y. /..---".„-/ 6.1. /0 Homeowner's Signature Date y � 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : �1�CY.3a ) l V c1 k y l 0 License Number StA,ctI re eiree4eAck. , NIA 0130 I 1� i Addre s Expire on D to _�nn '_ t a-4Y Ct �i (LAk5 yn 2 - Signature Telephone r� a ili " =at i. 6 Oa; (0)1 ` - - . _ . _ Not Applicable ❑ e 1 \0am ?(c s, `r C_ Company Name Registration Number 15 0.: S \Tee & fe R_f 1 r eAct I (l30 t c.3 ) 17— Address Expiration Dat Telephone (k113 - C)15"k i V ,9 Cy �,�`,�"�: � .:, q.q��YE' t0,)dipc° Al';i � (' ��` Sa hx.# � - _ �x'- r�t'�.r1�,'�,�°`•.'r7"�'� -.:'' �• �''¢€ ° art ©, gn:PA , vAf � _ s<. s_ �r !?r.�'"� 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 buildin permit. Signed Affidavit Attached Yes No ❑ , , t ij w * °vim 0 : Q I 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 4 3. C3.� Q�`l�i -® a`� �95�� 13rjg.t`e - a�'c^raos�: ® L'e New House ❑ Addition ❑ Replacement plows Alteration(s) [] Roofing ❑ Or Doors ®' Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [O] Other [o] Brief De cription of Proposed Work: ' -A . as ' •.. • • n._ 0.1A t . fl' • . a., ' (\s - . S ‘Jo Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes . No Plans Attached Roll - Sheet is E, ter 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. 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. floogplain 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 I , i ) v e 6 ' Y , as Owner of the subject property �_1 hereby authorize Pe AO. . Prodvc k 111C,- to act on my behalf, in all matters relative to wor authorized by this building permit application. (5,,e s„ o d C' mtroC - Cr1tIC k) Co/2.51 to Signature of Ovider Date I, Pz1 \0. -- v'R- d_ S Inc, - as Owner /Authorized Agent hereby declare that the statdments 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. Prin ame Signature of Owner/Agent Date J 9 9 , 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 j Lot Size 1 1 I 11 1 Frontage 1 1 I 1 I 1 Setbacks Front 1 I I I 1 I Side L:1 I R:I 1 L:1 1 R :I 1 .1 I 1 1 Rear I 1 1 1 1 1 Building Height I I I I I I Bldg. Square Footage I I I I% I 1 1 I 1 I Open Space Footage % (Lot area minus bldg & paved I I I 1 1 I 1 1 1 1 parking) -- # of Parking Spaces I 1 1 1 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Findin ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document It B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained I Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO t ► IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, descri e_size,.- type- and location: . ............ E. Will the construction activity disturb (clearing, grading, exca on, 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. ? City of Northampton r Building Department 212 Main Street . - Room 100 .. :.- Northampton, MA 01060 ph 4113-487-t240 Fax 413-587-1272 . <?3 \ . );) • LtO , 1.1 Property Address - ----- .. — 4 ,.- • 2.1 Owner of Record: z Oicxo Name Print) . CUrr nt M Hn Address: 0 Q\ d 7 Z Signature 2.2 Authorized Agent: Pe\\q P \xC • . \ ck S . C-iie 'jJrJ MA 0 I c Nam rint) f Current Mailing Address: Ct7 Signature . Telephone Item Estimated Cost (Dollars) to be com.)etedb .erimtas.Iicant -< 1 Building 72' -• --- - , - : 2. Electrical •..:-v-. -S 55555 3. Plumbing , c ,- - is. , • 2 s •.---- ------------ - 4. Mechanical (HVAC) -' - -5--, 1 5. Fire Protection 6 Total (1+2+3+4+5) iO 2 »3 SS - -S - 5- ---- fr' :t'1 -. ------------- - - - -S - - 5 5 5 55 5' 30 -' - rtale 42T ' ` BP- 2010 -1202 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 071 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 -1202 Project # JS- 2010- 001736 Est. Cost: $10543.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 7318.08 Owner: KAHN DANIELLE Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 42 DAY AVE Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON :6/28/2010 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 6/28/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo