10B-106 (4) PELLA PRODUCTS INC
155 MAIN STREET
GREENFIELD, MA 01301
413-772-0153
t C"VA~
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,lnc. 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
Department of Industrial Accidents
J BostOffice of Investigations
' d 600 Washington Street
y`
on, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiotVtndividual):
Address:
City/State/Zip: 1 1;. :c' a� �- e'1C u)"A (s 1 t 1 Phone #: t 4 ; ° -1 7-) C)
Are you an employer?Check the appropriate box: Type of project(required):
1.2"1 am a employer with-'-I �_ 4. ❑ I am a general contractor and 1 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. 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
required.] officers have exercised their 10.❑ Electrical repairs or additions
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
.I.
insurance required.] employees. [No workers'
comp. insurance required.] 13T] Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
.r 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+oust attached an additional sheet showing the naune 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 lite policy and job site
information.
a
Insurance Company Name: -� C_Ck C,
Policy#or Self-ins.Lie.#: ��'C,; it(�.�t _ �� - �\ Expiration Date:
Job Site Address: l-c,<� t�_l j T i_ i_ t-n.�;�s 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 wider 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 forin 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 the Rains and p nalties of perjury that the information provided above is true and correct.
Sig
griature: ( i� �_C Date: - CSC _
Phone#: 14 1 _�
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#:
911 e
Board of Buildin Re ula4L and
g g Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 142279
Type: Private Corporation
Expiration: 3/24/2010 Tr# 263223
PELLA PRODUCTS, INC.
GARY SHERMAN -
155 MAIN STREET
GREENFIELD, MA 01301
Update Address and return card.Mark reason for change.
0 5oon-07/07-PC6490 �] Address ❑ Renewal R Employment Lost Card
3�1zearrz�rcor o ✓`lavoczc�iueelY4
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 142279 Board of Building Regulations and Standards
s: Expiration: 3/24/2010 Tr# 263223 One Ashburton Place Rm 1301
Type: Private Corporation
Boston,Ma.02108
LLA PRODUCTS,INC.
,RY SHERMAN
i MAIN STREET
',EENFIELD,MA 01301 Administrator Not val' ithout signature
�, ✓�ze �n�r+rr�roreTUeaICL; a�U���ac�iu�efta
Board of Building Regulations and Standards
—= License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 142279 Board of Building Regulations and Standards
One Ashburton Place Rm 1301
g4 Expiration: 3/24/2010 Boston,Ma.02108
Type: Supplement Card
FELLA PRODUCTS,INC.
PAUL PICARD
155 MAIN STREET C L
GREENFIELD, MA 01301 •
Administrator Not valid without signature
,'roposal for Customer Project: Black, Rachel Quote No.: 38DP10 Alternate No.: 1
accountant fees for collecting outstanding accounts.
The Buyer agrees that the need date is a realistic estimate of when the product is to be delivered. Items remaining in our warehouse for more than 30
days beyond the agreed to delivery time will be subject to a storage and handling fee of 1% of the net amount of the order ($25.00 minimum charge).
The Buyer agrees that the product can be delivered without the Buyer present and agrees to accept the shipping documents as proof of delivery. The
Buyer agrees not to hold the Seller responsible for any damage to driveways, sidewalks, trees and overhead wires caused by the Seller's delivery
vehicles.
The Buyer agrees to examine the product(s) upon delivery and within 7 DAYS OF DELIVERY provide the Seller notice of any discrepancy between
the product(s) ordered and the product(s) delivered, including hardware. If the Buyer does not provide notice within 7 days the Buyer accepts the
product(s) as is.
160— � �� Taxable Subtotal $ 2,902.52
Customer Signature ella Sales Repre e tati e Signature
MA at 5.00% 145.1
None at 0.00% 0.001
None at 0.00% _ 0.00
Non-taxable Subtotal 2,360.00!i
'Total
�— $ 5,407.65
Date Date Deposit—Re ceived 00
WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated
into and become a part of this contract. Please see the warranties for complete details, taking special note of the two important notice sections
regarding installation of Pella products and proper management of moisture within the wall system. Neither Pella Corporation nor branch will be bound
by any other warranty unless specifically set out in this contract. However, Pella Corporation will not be liable for branch warranties which create
obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening (egress) information does not take into
consideration the addition of a Rolsereen [or any other accessory] to the product. You should consult your local building code to ensure your Pella
products meet local egress requirements. Per the manufacturer's limited warranty, unfinished mahogany exterior windows and doors must be finished
upon receipt prior to installing and refinished annually, thereafter. Variations in wood grain, color, texture or natural characteristics are not covered
under the limited warranty.
Proposal-Page 4 of 4
Office Order Copy
PELLA PRODUCTS, INC. 15
240 MOHAWK TRAIL
GREENFIELD, MA. 01301
Phone: (413)774-7231 Fax: (413)774-6348
Customer Project Ship-To Order
Black,Rachel Black,Rachel Order No. 73938DPI0I Order Date 05/30/2008
2 Florence Street 2 Florence Street Customer No. 52H500171 Need Date 06/25/2008
Tax Code MA Sales Rep. Code 41
LEEDS,MA 01053 Leeds, MA 01053 Taxable no Sales Rep.Name Picard,Paul (53)L.
HAMPSHIRE HAMPSH Tax Exempt No. Window Store 000003
Terms Code C.O.D. Territory
Lic.No.: P.O.No.: Customer Type Ship To County HAMPSH
MDR Code SP Prepared By Paul
Rachel Owner: Ms. Rachel Black Overall Discnt. -3.369% Architect Name
Bus. Phone: (413)586-4272 Bus. Phone: (413)586-4272 Comm. Split 41: 100. % Dist. Order No.
Bus. Fax: ( ) - Home Phone:
Cellular: ( ) -
Home Phone: ( ) -
Delivery Instructions: : 91 s to exit 20,turn right at light,right at stop sign by Look Park, left on to Florence Rd.just past VA Hospital. Go about 1 mile turn right at second
trrance to school there is a driveway. House is set back behind school.
Comments:
Outside View Item Qty. Description Unit Priee Extended
Item# 10 Qty: 1 Right Hinge Casement,Frame:27-3/4 X 37-1/2: Architect Series, Clad. 488.29 488.29
Location: Stai,way Model 2,Brown, 518" InsulShld IG Glazing. Champagne Screen. Champagne 24.41 24.41
R.O: 2' 4-1/2" X 3' 2-1/4" Hardware. 3-11/16" 512.70 512.70
WallCond: 3-11/16" -5.000%
Notes:
Item#25 Qty: I Right Hinge Casement,Frame:27-1/2 X 37-112: Architect Series, Clad, 488.29 488.29
Location: Sons Room Model 2,Brown, 5/8" InsulShld IG Glazing, Champagne Screen, Champagne 24.41 24.41
R.O: 2'4-1/4" X 3'2-1/4" Hardware, 3-11/16" 51170 512.70
WallCond: 3-11/16" -5.000%
Office Order Copy-Page 1 of 4
06!'03/2008 14: 16 4137743872 MASS ONE INS PAGE 01/02
AAWWO,- CERTIFICATE OF LIABILITY INSURANCE s`coos
PRODUCER (413)773-9913 FAX s (413)774-3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY MaeSIOne Insurance Agency HOLDER�THISO CERTIFICATE R OES NOT AMEND, EXTEND OR
117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. HOC 538
Greenfield MA 01302^0639 INSURERS AFFORDING COVERAGE NAIL
INSURED INSURERA;,AMadia Insurance Coepany 31325
P811a Producta, Inc. INSURER 8;
ATTN: John Benjamin INSURER C:
155 Main 9 treat INSURER O;
Greenfield I MA 01301-3258 INSURER E:
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 $UBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
V
1NSR ADD' POLICY EFFECTIVE POLICY EXPIRATION LIMITS
KqR TYPE OF INSURANCE POLICY NUMBER DAYS MMfD DA MMID
GENERAL LIABILITY S 1,000,000
X COMMERCIAL GENERAL LIABILITY _ Is TO RENTED e S 250,000
A CLAIMSMADE a]OCCUR CPA020470111 1/1/2008 1/3,/2009 MED 522 fAny aria e $ 10,000
v IV 5 1,000,000
QfiWEAA4A2GRFGATF! $ 2,0001000
'0001R00 GEN'LAGREGATELIMITAPPLIESPER' _
X LOC
POLICY 7 PRf�
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Eaowdent) $ 1,000,000
A ALL OWNED AUTOS NAA020470211 1/1/2009 1/1/2009 BODILY INJURY
(PM person) $
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY 9
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE 3
(PeracoWAnq
GARAGE LIABILITY AUTO ONLY.6AACCIDENT =
ANY AUTO OTHER THAN Ca ACC $
AUTO ONLY; -6130 $
EXCESSRIMBRELLA LIABILITY $
OCCUR U CLAIMS MADE AGGR OU5 S
DEDUCTIBLE $
R
A WORKERS COMPENSATION AND WC 9 OTH-
EMPLOYEFW LIABILITY
ANY PROPRIF-TaRtPARTNERIEXECUTIVE L.EACH ACCID NT $ 500,000
OFFICERIMEMBEREXCLUDED? wCA020470511 1/1/200$ 3,/1/2009 EL.DISEASE-_E MPLOYEE$ 500,000
It yes,dew1be under
-$EEQA PROVISION$ DISEASE- 1 Y LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESnE(CLL9IONS ADDED BY ENDORIVMENT/SPECIAL PROVISIONS
Ogerationa usual to the sale & installation of doors S windows
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE A90VF DESCRIBED POLICIES BE CANCELLED BEFORE THE
Rachel Black EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
2 Florence Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Northampton, M,A. 01053 FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURE ITS AGENT'S OR REPRESENTATIVES,
atfTHORIZEQ REPRESENTATIVE
RObi,n Sargent/TG
ACORD 25(2001108) t9 ACORD CORPORATION 1988
INS025 rmo8l.om Page 1 of 2
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered ome`Improvement Contractor: Not Applicable ❑
Company Name Registration Number
- l' Il , t `fd 0� X71 k)t` t
Address
Expiration Date
TelephoneH 1,3,
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.
L.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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacementindows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [C] Siding [0] Other[O]
Brief Description of Proposed ��
Alteration of existing bedroom �Yes � No - Adding new �� � �� � � ��
g
Work: � �t.
w bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New 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
property `- \ lti`�
as Owner of the subject
hereby authorize 6 1 ' ,1 , _ t �'v Ct r t�.�t-A U l >C
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
\ r �"1C9��;.1 � �� �:�; CY'�1` � 1 � t 1 �
, 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.
i 'Z"�"Lk
Print Na
igna a of Owner/ g 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
(Lotarea 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 DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page 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 Q Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northamp ton Statuf fm
Building Department �urtrc iveway Permit
212 Main Street Sewer/Se ticAvalfabllity
Room 100 u i Wgtel Availabl�ity
Northampton, MA 01060 Two Sets of Structural'-Plans
phone 413-587-1240 Fax 413-587-1 272 P
Q lxe F1 fy
APPLICATION TO CONSTRUCT,ALTER,REPAIR, IkENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
e"A `" F k. Ma Lot Unit
Q Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��;J��V1<_Via, _�'J 4(?—(. �'s �:%� t f i"�Q" C V\Z r �)� �. 1.f'�_' ,�( 1.:.`_✓ E� �!°'�
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Outhorized Agent:
Nam Current Mailing Address:
Sign At ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted 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)
5. Fire Protection
6. Total= (1 +2+3+4+5) f Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-1103
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-2008-1103
Project# JS-2008-001628
Est.Cost: $5408.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 142279
Lot Size(sq. ft.): 57934.80 Owner: BLACK RACHEL LIVING TRUST
Zoning.URA Applicant: PELLA PRODUCTS, INC
AT. 2 FLORENCE ST
Applicant Address: Phone: Insurance:
240 MOHAWK TRAIL (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON.61912008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 7 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 $25.0030213
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo