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10/10/2007 15:58 4137743872 MASS ONE INS PAGE 03/03
ATE�, CERTIFICATE OF LIABILITY INSURANCE I o 2 a
QRD
PRODUCER (4.13)773-9913 FAX: (413)774-3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MassOne Insurance A anc ' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
� HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 638 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
117 Main St.
Greenfield MA 01302-0538 INSURERS AFFORDING COVERAGE NAIL
INSURED INSURERA:Acadia Insurance Company 31325
Fella Producta, Tne. INSURER 0:
Attn: Cohn Benjamin INSURER C;
155 Main street INSURER D:
(Greenfield MBA 01301 INSURER E;
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVMTHSTANOING 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 RY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T1iE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
.4-REDUCED
INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY IMMFOOnvE POLICY LIMITS
GENERAL LIABILITY $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE 70 RENTED $ 250,000
A CLAIMS MADE I OCCUR CPA020470110 1/1/2007 1/l/2008 MEDEXP(Anyone erson $ 10,000
-PROUNAL&ADY INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GE TE LIMIT APPLIES PER: p p AQG $ 2,000,000
R LI Y PRO-
0
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea xdden() $ 1,000,000
A ALI.OWNED AUTOS MAAL02 047 0210 1/1/2007 1/1/2008 BODILY INJURY
X SCHEbULED AUTOS
(Per pawn] S
X HIRED AUTOS BODILY INJURY $
7C NON.OWNRDAUTOS (P�ecddent}
PROPERTY DAMAGE $
(PCr aetltlOM}
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTO OTHER THAN FA ACQ S
AUTO ONLY: AGG $
rXCESS1UMBRELLA LIABILITY EACH OCCURRF CE $
OCCUR CLAIMS MADE AGGREGATE S
S_
DEDUCTIBLE $ W
RETENTION
$
A WORKERS COMPENSATION AND 8 G 9TATU- OTH-
EMPLOYER$'LIABILITY ER
ANY PROPMETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT S 500,000
OFFICEWMEMSEREXCLUDED? wen020470610 1/1/2007 1/1/2008 E.L.DISEASE•EAEMPL YEES 500,000
If yes.describe under
I SONS below F.L.DISEASE-POLICY I S 500 000
OTHER
DESCRIPTION OF OPERATIONS IIOCATIONSNEHICLEVEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Operations usual CO t" 8A10 R installation of doors & win4pws
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Lisa Bombard EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
89 Dreween DX 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Florence, MA 01092 FAILURE t0 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108) a ACORD CO ORATION 1988
INS025(aiw).om Page I or
-- Pella® Windows & Doors
4
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DC
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4i 3^`5$�
I
Subject: Disposal of Debris
The purpose of this letter is to certify that all debris from any project
undertaken by Pella Products, Inc, in Berkshire and Franklin counties
will be transported to a dumpster at our plain facility at 155
Main Street, Greenfield, MA. 1
Pella Products„ Inc. is under contact with Waste Management of
Massachusetts for the disposal of the contents of this dumpster.
I
i
Very truly yours,
PELLA PRODUCTS, INC.
John P. Benjamin
Accounting Manager
Generic Debris 05-23-07.doc
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1
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Pella Products,Inc.
155 Main Street
Greenfield,MA 01301
Main Office Phone.413.772.0 f 53
IEWED TO BE TH B S Service:800.957.3552
L FN LlJ 1!J 1- 1L 1L Fax:913.773.11581
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wrvw.mass.1-3,ov/dis
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nanne (Business/Organization/Individual):
Address: `7`J
City/State/Zip: 5 P C 1`\ _ A OVI Phone#
Are you an employer? Check the appropriate box: Type of project(required):
1. — I am an employer with _I:Z___ 4. — I am a general contractor and 1 6. — New Construction
Fmployees(full and/or part-time)* have hired the sub-contractors
2. — I am a sole proprietor or partner- listed on the attached sheet. I 2• — Remodeling
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. — We are a corporation and its 10. — Electrical repairs or additions
required.] officers have exercised their
3. — I ann a homeowner doing all work right of exemption per MGL 11. ~ Plumbing repairs or additions
myself. [No workers' comp. C. 152, ' 1(4),and we have no 12. — Roof repairs
insurance required.]H employees. [No workers' 13. — Other
comp. insurance required.)
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
H Homeowners who submit this aiff clavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I Contraclots that check this box must attach an additional sheet showing the name or the sub-contractors and their workers'
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-C _r').A��: t l`��► (.tr1(, __ hl .
Policy#or Self-ins.Lie. #: � �! ( Expiration Date:
Job Site Address: For all.FCCIP towns 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 fine up to
$1,500.00 and for one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tune 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 herehp certify under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: d
Phone#: '4 L-3 I -M - D i s3
Of.f cial use only. Do not write in this area,to be completed by city of 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#:
5
y�'� _,, ,lL//,y/11�f'� t��y�/�.�i��'liL��it�i�!i!Zlli' Q'�t_../��/J•.
�( Board of Building lie gula ions and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 142279
Type: Private Corporation
PELLA PRODUCTS, INC. Expiration: 3/24/2008
GAR)' SHERMAN
155 MAIN STREET ----- __.
GREENFIELD, MA 0.1301 - --- - --
Update Address and return card. Nlark reason for change.
,ora-o�(o i coe�e
E] Address 0 Renewal ❑ Lmpluymeirt Lost Card
.' L< ��Cy9/1.7YlOJ(CL4'[Y.(.CIL Gf�✓/ � .____.-_._. _____-_ ..
Board of YYuittliug Rc6uhttions and Standards
' HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
before the ex iration date. If found return to.
Registration: 142279 Board of Building Regulations and Standards
Expiration: , �
3/4/20.8 One Ashburton Place Rrn 1301
Type: Private Corporation Boston,Iyla. 02108
ALA PRODUCT S, INC.
,RY SHERMAN
MAIN STREET
;EENFIELD, MAD 1301
Administrator ---�Not valid tt►out signature —
�\ :���ze C�'oJJLiie�rocueczcl`� ���,`�ac�ivaeC,�ri
Board of Building Regulations and Standards License or registration valid for individul use only
if ( HOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
Registration: 142279 Board of Building Regulations and Standards
Expiration: 3/24/2008 One Ashburton Place Rnt 1301
Type: Supplement Card Boston,Ma.02108
PELLA PRODUCTS, INC.
PAUL PICARD
155 MAIN STREET
GREENFIELD, MA 01301
Administrator Not valid without signature
i
�ti.
SECTION$-CONSTRUCTION SERVICES
8.1 License Constr- ction Suparvi5ar: Not Applicable O
NoMe_of Lice_nAe Holder
License Number
Address Expiration Date
Signature Telephone
road` m�rsyiittmerl Cnutrf3 i,�.: ,� ?; Not Applicable 0
Company Name Registration Number
-
Addres Expiration Data
T®lephone'�13-�1�-o1S3 �, aUU�
SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL,a.163,§85C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affldavit will result
In the denial of the issuance of the building permit.
Signed Affidavit Attached Yes...,... No...... O
1�. 112 m� i0wn�r��emtat><+
The Current exemption for"homeowners"was extended to include Owner-occupied Dwellings 4f one(1) or two(2)fdmi lies
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as sn,new Vr CMR 780 Si&th Edition Sedign 108.3.5.L.
Definition of Ham o�wner Person(s)who own a parcel of lend 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 thtm one home ig 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,t„ at he/she s all be
responsive for all such wo k performed urrdeX the building permit.
As acting_ConstructlokSuperylspr your presence on the job site will be required rroin 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 persons)
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 Mamachusctts General Laws Annotated.
Homeowner Signature
took ZLZT 999 XYd TZ:OT LOOZ;W�0
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SECTION 5•.0ESCRIQTION OF P QI SED OK( heck all appl[cab10)
New House ❑ Addition [] Replacement lndows Alteratlon(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition 0 Now Signs [fl] Decks [M Siding[CI] Other[[7[
Brief Description of Proposed
Work: (_ e--I) VAL2, Lipp naA%e xderor f,( etc?�S �L
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No V1 P_��
Attached Narrative Renovating Unfinished basement Yes -No
Plans Attached Roll -Sheet
a. Use of building,One Family Two Family Other _
b. Number of rooms In each family unit:_ Number of 9athrooms_
c, Is there a garage attached?
d_ Proposed Square footage of new construction. Dimensions
P. 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
j_ Depth of basement or cellar floor below finished grade _
k. Will building conform to the Building and Zoning regulations? Yes _No.
1. Septic Tank __ City Sewer_ Private well __ _ City water Supply
:SECTIONS 7a.,:DWNER AUTHORIZATION-TO:BE COMPLETED.WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
M4�C<- as Owner of the subject
property +
hereby authorize ,\�(�_ �( t^�.t,��{"`� (��_,•
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Gate
I, 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.
Slgne er the pains naltles of perjury.
i;MVft, a
of�Ow, Date
�OOI ] ULZTL82ZTb XBd TZ:OT LOOZ/t0/50
Section 4. ZONING All Information Mutt 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,
Frontage
Setbacks Front L
Side L-= R:=
Rear
Building Height
Bldg.Square Footage r
Open Spacc Footage %
(Lot area minus bldg&paved
parkin&2
#of Parking SEaces
Fill:
(volume&Location)
A. Has a Special Perm it/Variance/Finding,e I ver been issued for/on the site?
NO Q DONT KNOW 0 YES
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[— ..... .......
i j and/or Document#!
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed change§to or additions of signs intended for the property 7 YES 0 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 I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW Is required.
%Z%92STV XVJ TZ:OT LOOZ/rO/SO
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Clty'of Northampton
#Gi i
�,.' , ��f,,-' ✓,�U�
Building epartment
•—�, ��7 r' "'reay
2't2 Mai Street y��+: , Z
5m 100
� r
Northampton, MA 01060
phone 416-567-1240 Fax 413-567-1272 ? i4µ 1
APPLIC90N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY,DWELLING
SECTION 1 -SITE INFORMATION
1,1 PrOD9 Address: This soctlpn to,be completed by office
I S 1J C l J Q,,, Map Lot Unit
Jr f-Ace 011,0lo aZ
Z4ng_ Overfay District
Elm St.Distrl CB Diatrlct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Namo(Print) Current Mailing Address:
q(3 5�{�-'11��'
Telephone
Signature
2.2 Authorized Anent:
.CA S Za[' __I 5 5 00.ck k, (A L'+ 0 CA V�(i c��3u I
Nam Current Mailing Addreas:
a - ytS3
n ure T"Itsphone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Otfeial Use Only
completed by ermit 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)
S.Fire protection
6, Total n(1 +2+3_+4+5} Check Number
This Section For Official Use Onl
Building Permit Number. Date
Issued:
Signature:
Building Comm isslonerlinepeetor of Buildings Date
TOO z 'L(TL82CTV XVi TZ:OT L009/VO/50
101"11" NMI,
�r BP-2008-0403
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0403
Project# JS-2008-000589
Est. Cost: $2004.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 142279
Lot Size(sq. ft.): 9016.92 Owner: BOMBARD LISA
Zoning: SR Applicant: PELLA PRODUCTS, INC
AT. 89 DREWSEN DR
Applicant Address: Phone: Insurance:
240 MOHAWK TRAIL (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON.1011612007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 10/16/2007 0:00:00 $25.0027981
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo