38B-144 PELLA PRODUCTS INC
155 MAIN STREET
GREENFIELD, MA 01301
413- 772 -0153
� c (I t c (
S \ s 1C .\ r \7< " r IJC)T., 1 ∎i ∎:;
Subject: Disposal of Debris
The purpose of this letter is to certify that all debris rusulting from any project undertaken by Pella
Products Inc. in your Town will be transported to a dumpster at our main
facility at 155 Main St. 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
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41 tf
The Commonwealth of Massachusetts
* Department of Industrial Accidents
Pt. mow �,4
1 Office of Investigations
600 Washington Street
y y
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /OrganizatiotvIndividual): -e 1,164_. _ (A
Address: l 0 t1 s �_
City /State /Zip: (7); wl C' 1(),( �l A 0 1 Jt`` 1 Phone #: cf. ; ... ° 1 - 14 -
Are you an employer? Check the appropriate box: Type of project (required):
1. Pi' 1 am a employer with _ `1 '"S _ 4. ❑ I am a general contractor and I 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. t 7 . ORemodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. [11 We are a corporation and its
required.] officers have exercised their 10111 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t 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.
$ Contractors that check this box must attached an additional sheet showing the name of the sub- contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for niy employees. Below is the policy and job site
information.
Insurance Company Name: y C. Cti :31 kJ' (VV AL
Policy # or Self -ins. Lic. #: Lk) - i -\ C),-4 - 0 `_ 1 r< Expiration Date: 31 D t (-) 1 ; c -
Job Site Address: { r� 1 i 5 City /State /Zip:
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
tine 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 tine
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.
1 do hereby certify under the sins andp nalties of perjury that the information provided above is true and correct.
Signature: ( (Awl/ 1 t Date: / _- r.)
Phone #: > ,3 7 7 r) - C J 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 #:
l. .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
e Oa or L.l,(. K , (\c° . i ,1 00--) ct
Company Name (f \
L �{ 1 Registration Number
1 55 Y 1�∎ (5 1 J�(',eC\"' \,E'�C7. A- O \✓Q11 i'i /3Ct
Addres Expiration Date
/ /�.v/ Telephone 77J-64
SECTION 10- 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 buil ing 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
e
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement_Wjr�dows Alteration(s) E Roofing E
Or Doors ��
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other [0]
Brief De,scription of Proposed
(
Work: „(>tiSk-)k I ko Lki■ A CkL)is. t (\ e caj)i= 4'tt ; I � \v ' C"( - r` u Li fWL� Vtizr tc-
0 , 3 tte ( J 1>
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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
I, r C ,'Yt � c'ir ,.3 (:) I o.. AV)�).,.5 ii -U c , ` w: �� \o..t v ) k Q!1 KT\ , as Owner of the subject
property
hereby authorize r k l C>z �c ��6.t} `=y ...C-4 ...C-4 \ci re 4 O y 1 p' " .,..;\4:k i L1..• (. LE -, e k(�. ���t"t 1
to act on my behalf, in all matters relative to work authorized by t is building permit application.
Signature of Owner Date
I, e \ Q:)..- e(c kkt._k- .. cY \C . t " 5 'l l\a..∎ 1 ! ),_ ° V ( C ,f1 \■ el Ci , (y\A , 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.
Signe er the pains and enalties of perjury.
Print N.mp
1 4 7— L�L _I
S gna - e of Owner /Agent Date
o
�� Department use only
Ctty of Northampton Status of Permit:
Builig'Department Curb Cut/Driveway Permit
' 212 Ma Street Sewer /Septic Availability
, 00 Water/Well Availability
Nc 'a�np MA 01060 Two Sets of Structural Plans,
s.
phor�e`'4i't 240 Fax 413 - 587 -1272 Plot/Site Plans
�� .
f r ' Other: Specify
APPLICA1 bN TO'CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - BYTE INFORMATION
1.1 Property Address: This section to be completed by office
) 3 Co (1-J lv Map Lot Unit
r-1/4)0. (, '1 . Y\ v t 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
,_\ d 3 L.0l V- 0 e \ (,.,
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent: / ( { +
�) .. C.1. V a (k),( .3 .� r� � l ,e� \ Y1(f. { ` c _ L F . k t tc . \ r lil
Name Pr' . Current Mailing Address:
fi e „ P W / ! L 1 ) ) -..1 ■ 3
ure Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) I t- t e t0 , .I Check Number 3(} .7 / y A 3 —
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
µ ) .,. ' BP- 2008 -1104
GIS #: COMMONWEALTH OF MASSACHUSETTS
:iN 4 :4 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- 2008 -1104
Project # JS- 2008 - 001629
Est. Cost: $12490.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 142279
Lot Size(sq. ft.): 6098.40 Owner: LONDON NAOMI D
Zoning: URl3 Applicant: PELLA PRODUCTS, INC
AT: 23 COLUMBUS AVE
Applicant Address: Phone: Insurance:
240 MOHAWK TRAIL (413) 772 -0153 WC
GREENFIELDMA01301 ISSUED ON:6/9/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 16 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 6/9/2008 0:00:00 $25.0030214
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo