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Cl) c7 M G O r M N n Z •1 sz, DGO 3 r p � v CL.r- O O 0 z z _ 0 < o D . � Z N n m m co CL Co m � mG7 v z D H O — =Om Sac, n --1 p o = m m m0 > = A z ° Q 3 n 'a m -< K _ CL M cu y m co rn N = J=f 7 = N O 0 CD O m 0 -a CL ' s mm z � � ° z 0 � ° U o 0 c° v O '� AfJO G7 p ton m .�+ y t'D N y CD rt fD tD m G) c f a_r °L cv o p m cc oZi p Z cmDm C C m y ° y 0 to y m o m 3 d �' v = N 3 u Cr Cl)z z — 3 3 m cs m t� cn cn m C C 6 � (CD c O N U1 v rrr p D C? o0 o m ( v o w w m °: n�i o 3 ° m = y OD Z R 3 CL ,_r w D a�i 3. y <_ A co m O o w CD o p CD 3 TJ N m cn 3 N w oo m 3 S O w o m D O C) .(1 Cl m > n. CD CD 0 a ° Cl O c a m mo O A c cn a --I fD fD 7C m 0 • '. m C " 3 m r v v N () a � o X su m O w z o H O m m oD z c D co o m — N ;u v b ° O m a, rn m D. !rtD U) N O ^'. 0 O m to z m o N m rl m n 0 z PELF PRODUCTS INC 155 MAIN STREET GREENFIELD, MA 01301 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 The Commonwealth of Massachusetts n Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 111A 112111 "C www.mass.govldia Workers' Compensation Insurance Afkidavit: Builders/Contractors/Electrieia ! lumbers Applicant Information Please t Legibly NM11C (13tisiness/Organization/tntlividital): -- Git /St:lte/Lip: 77fr:,c�? i �� Ivl� 0 / Phone #: Are you an employer? Check the appropriate box: Type of project uired)- 1.[� I alp a employer with_! _ 4- ❑ I am a general contractor and f employees(full atidior part-tirtle).* have hired the sub-contractors ti. ❑New con,, &&ion _.❑ f zuYl a sole proprietor or Palmer- listed on the attached sheet. 7. ❑ Remodel' ship and have no ennployee These sup-contractors have 8. ❑ DemOlit.ioi-1 \vorlung Por the in any capacity. employees and have workers' 4. ❑ Building ,'`ion [No workers' comp. insurance comp. insurance.f >. We are a corporation and its 10.❑ Electrical f•. airs or additions i required.] ❑ 1 `�. ❑ 1 ant a homeowner doing all work officers have exercised their t 1.❑ Plumbing(',fig airs or _dditions myself. No workers' comp. right of exemption per MGL, v [ 6 12.M Roof repov_'> insurance required.]'1 c. 152, S 1(4), and we have no t, employees, [No worker' 13.❑ Other comp. insurance required] 'Any applicant that checks box 41 ttwst also till iwt tale section below showing their wort er,'cotnpensadpn policy in1'onnation. Nomcownccn Who Submit this al'tidcivi4 indicutiug they are doing all work and then hire i,utidr cunlradors must subnut it new aPGda ndiealiD.L�:;uch. 4-onvaciois tliat check this box must attached im additional sheet showing the name oC[Ile soh-eantractos caul state whether or nut the sntilic,Ita'•c. ,�ntployces. It'the sub-oontraetors have employee~,they must provide their workers'comp.policy nu,nber. 1 am an employer that is providing workers'compensation insurance.for my emplovees. Below is the Pot anti job site information. Insurance: Company Name: _V- —r- � Gt rri , C - r _ Policy #or Seff ins. Lie. #:����/-f jl�[ �' -���-���- l �piratioll Date: Job Site Address:^ Kl RoCI City/State/"Zip:_ ''j -.T�� 0'�F L Attach a copy of the workers' compensatio policy declaration page(showing the policy number and dpiraticil,date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of Grim al penalties of a fine up to $1,500.00 and/or one-year iniprisomnent, as well as civil penalties in the form of a STOP WO" )RDER and a fine of up to $2.50.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to tt 0ftice of Investigations of the D1A for insurance coverage verification. 1 do hereby certify under the pains and penalties uj*perjurt,that the information provided above is true:a correct. i C Si�,tlature: An. c�k ' � Date: / �� � � � �• V / `--� Phone #: tI ` -� � �L;�3 � _— — --f Official use only. Do not►vrite in this area, to he completer)by city or town ojjicial. City or Town: Permit/License# Issuing Authority(circle one): I, Board of.Health 2. 'Building Department 3, City/Town Clerk 4. Electrical Inspector S. Plumbin uspector 6.Other Contact Person: Phone M. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ` J] Not Applicable ❑ Name of License Holder: Q 1 0� (�4UXQ, —� L f V96 6 License Number Address - J Expiration Date i Signature T;lephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number f_�s �yUt n ►-To ► 3-ZL9 -1 Y Address (� (L-L-772 Expiration Date Telephone 'CIS 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 buildingpermit. 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 buildine 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) r New House F_� Add Lion Replacement windows Alteration(s) Roofing E] Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [Q Siding[[3] Other[❑] Brief Descri ion of r posed Work: 0_11XTUA . Alteration of existing bedroom Yes�No Adding new bedroo Yew No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existina housina, 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, (� as Owner of the subject property hereby authorize P �01 & .�� C . to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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. �zn. J di�__ Print c(;J C. _0 Signature of Owner/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 tilled in 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 parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO U DON'T KNOW � YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ki DON'T 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 ® DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of No h6hll-ton Status of Permit: Building D o � rtme � u 0u Cut/Driveway Perm it Z 8 204 �e212 Mai tree r/Septic Availability Roo 10Q W ter/Well Availability Northamptoll; 'R4A;Ohp60 ' -cti fi Sets of Structural Plans phone 413-587-124 FaiC41-S--587.1-2 ft t/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Z I)0,,0 Cfz-�T ' U(1 Map Lot Unit 61 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: [ d f& Name(Print) Current Mailing Addres Telephone Signature 2.2 Authorized Agent: ?cUi I t l Name(Pr `' t) Current Mailing Address: C �,��h 41 3 - "777 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of G Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+.4+5) p 0, Ci) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 102 BANCROFT RD BP-2014-0830 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D-308 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Window replaced BUILDING PERMIT Permit# BP-2014-0830 Project# JS-2014-001437 Est. Cost: $3200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 22564.08 Owner: STARR DAVID J&JULIE Zoning.URA(100)/ Applicant: PELLA PRODUCTS, INC AT. 102 BANCROFT RD Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC GREENFIELDMA01301 ISSUED ON:112812014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 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: 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 1/28/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner