36-055 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
IN Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual): Q��I(( _ froC1UC.-S T_ncr '
Address: 1S5 t Ct n Z_:He,k
City/State/Zip: &-eimTi e-A d ,MA- d 1'3 D I Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with —15 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.t �• E]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
officers have exercised their 10.❑Electrical repairs or additions
required.]
3.❑ I am 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.]t employees. [No workers' 13.0 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 my employees. Below is the policy and job site
information.
Insurance Company Name:Actd a_ T_r)S,Lt. -0n r_
Policy#or Self-ins.Lia#: WC — A DI —Q y_1 V 5 i b Expiration Date:
Job Site Address: 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/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 c y under the ins and penalties of perjury that the information provided above is true and correct
Sign Date: 1L9k:7
Phone#• L4 1 3 --1_7 3 — 15 -7
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#:
IS 08: 4 3 a Acct
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement-Contractor Registration
Registration: 142279
Type: Private Corporation
Expiration: 3/2412008
PELLA PRODUCTS, INC.
GARY SHERMAN
155 MAIN STREET
GREENFIELD, MA 01301
Update Address and return card.Mark reason for change.
WS-W 0 WM4054'Ca0a E) Address [] Renewal n Employmint [] Lost Card
Board of Building Regulations and Standards License or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return tot
Registration: 142279 Board of Building Regulations and Standards
Expiration: 3242008 Out Ashburton Place Rm 1301
Boston,MR.02108
Type: Private Corporation
PELLA PRODUCTS;INC.
GARY SHERMAN:
155 MAIN s7fkEEr.
rz,
GREENFIELD,MA 01301
Administrator Not valid hout signature
.......... ...... ... .........
Site Responsibilities and Terms of Sale
Pella Products, Inc.
155 Main St.
Greenfield,MA 01301
(413)772-0153
Customer: David Neal Date: 6/5/2007
Order#: 73927FB071 Signature:
Salesperson: Michael Balthazrr Signature:
1 50%Deposit required at time of order,balance due on the morning of the last day of installation.
2 Payment is to be made to installation team.
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 postpone and
reschedule the project.
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 Pella will call with approximate installation dates. These dates will be confirmed prior to install.
9 Unforeseen rot repair can be quoted on site as additional work
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
Pella Will Owner Will
Ox 0 Secure all necessary Building Permits
x F-1 Deliver and unload products
FT] Place drop cloths in work areas
Remove&reinstall interior and exterior trim if applicable
0 Remove&reinstall existing shutters and awnings by contract
x Remove existing product and adjust or modify opening as needed
Provide all equipment necessary to install products
Cut all wood and other materials outside of home
0 Install all products purchased
Insulate and caulk around products
xx [] Remove stickers and perform initial cleaning of all glass surfaces
Demonstrate proper operation of products
0 0 Confirm that all products are in working order
0 0 Remove drop cloths,vacuum and remove all old products from premises
F-] J Finish(paint or stain)product purchased
0 Fx__J Cut-back or tie trees, bushes,shrubs from exterior wall
0 Arrange to have alarm system disconnected and reconnected
[] x[] Arrange to have any plumbing or electrical repairs or changes by _
appropriate licensed contractor For all service needs,
x Remove and reinstall existing window treatments,wall hangings and please call:
(800)957-3552
air Conditioning units. Please make sure you
0
FT] Remove and reposition furniture in work area
mention that your project
0 0 Secure pets in a safe manner was installed by Pella
0 0 Remove valuable/breakable items from work area and reference your order
E-1 FT-1 Remove snow from area of worksite if necessary number
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 ❑
On I Ili. Lau c_js zlc, . I q22 -7 9
Company Name Registration Number
ia5" tAQ-6-1 �A - 6'r MA 3 2y
Address
r ' t ' 2 Expiration Date
1
0 L3 Q Telephone q i3-J�3—i is
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 building permit.
Signed Affidavit Attached Yes....... No...... ❑
11 - Home Owner Exembdon
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 ❑ Replacement Windows Alteration(s) Roofing
Or Doors AL I
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[[�]
Brief Description of Proposed
Work: ala_'Aa,cklld�l, a �J-I.t.n 1 L hGi jil',13dow
Alteration of existing bedroom Yes_P<, No Adding new bedroom Yes V'i 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 r,'� 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
as Owner of the subject
property {�
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
S'e c Ca)�ro c.4 (P- 7 /Q 7
Signature of Owner Date
Alk pr1Ctu(Jr' J r C as Owner/Authorized
Agent hereby declare that the statements a d information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under he pains and penalties of p rjury.
U 4C
Print Name
Le lo
Signature of Owner/Ag 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 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 0 DON'T KNOW YES
IF YES, date issued:"
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book Page', and/or Document#'.
B. Does the site contain a brook, body of water or wetlands? NO W DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading ex avation, 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.
DeernSnt use only
r
, City of Northampton Sti bis M errnit
Building Department Curb Out/Driveway Permit
y 12 Main Street newer/ goticAvailebiii r
Room 100 WatermellyAu ilabillty.'.
Nc0rthampton, MA 01060 two Sets�of�Str cttiral,'Olans
�hone1�-587- 240 Fax 413-587-1272 PIotlSite Plans,
Other Speoify !"
t_—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
�I
4 G eeCjfV,- t1 Con-d Map Lot Unit'
MA NCO- Zone Overlay District
Elm St.district CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Su 1 i,1 l 1 tL Telephone
Signature
2.2 Authorized Agent:
Pte.Na- Prod uc;� s �� _1S15 M(u,,n Ist ��r�e Ad WA 0j,"w
Name(Print) Current Mailing Address:
Signature U 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 I (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) ) ' Z " Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2007-1223
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2007-1223
Project# JS-2007-001950
Est.Cost: $1724.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 142279
Lot Size(sq. ft.): 12501.72 Owner: NEAL DAVID A&KRISTYN M
Zoning.URA Applicant: PELLA PRODUCTS, INC
AT. 49 REDFORD DR
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREEN FIELDMA01301 ISSUED ON.611512007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 3 UNIT BAY WINDOW
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 6/15/2007 0:00:00 $25.0026695
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo