06-004 (7) BERKSHIRE INS Fax:14135684284 Jan 15 2015 16:48 P. 08
A � DATE(MMrpD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE FI/9/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOE.R.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOE$ NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: K the certificate holder Is an ADDITIONAL INARED,-the Pollcy(ies)must be endorsed. H SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain Policies may require an endorsement. A statement On this certif cats does not confer rights to the
certificate holder in lieu of such endomementIf ,
PROOMER C MTACT ROYf'iA Sargent
Berksb.i.re Insurance Group, Inc. PINE (413)773-9913 FAX
j.,(413)774-3972
1l7 ]!gain Street E-MAIL AmgFsg.rsargent:Bberkshireinsurancegroup,com
INSUR'U! AFFORDING COVERAGE NAIC(!
Greenfield MA 01301 INSURERA:CiLizeng Ins. C an of Amer 1534
INSURED INSURER0-.MX88iiLQh 88tt8 Bay -insurance Co 2306
Pella in Street inc. lN3UftRc The Hanover Insurance C a01 10212
155 DSaix1 3t:reet INSURER 0:
INSURER III:
Greenfield 3i INSURER F:
COVERAGES CERTIFICATE NUMBER:15GL,AL,WC REVIS16N NUMBER:
THIS 13 TO CERTIFY THAT 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 01=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 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
1 TR TYPE OF INSURANCE DDL POLICY tjUMBER POD EFF y L.ICY EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X 1 COMMERCIAL GENERAL UA91LrrY PR6Ml 6'i KERTED
de S lOfl,000
CLAIMS MADE OCCUR 8PI943720203 1/1/3415 /1(2016 MED FXP'I one pamon) $ 5,000
PERSON>VLBADV INJURY s 1,000,000
GENERAL!AGGREGATE S 2,000,000
tB ML AGGREGATE ljMrr APPLIES PER P{>;ODUC 1: -COMP/OP AGO $ 2,000,001)
FoucY 7C X Loc $
OMOBILE LIABILITY IFEMLI 1,000,000
ANY AU TO BODILY MURY(Par P--) S
ALL OWNED SCHEAULEO 1939977003
AUTOS AUTOS BODILYIN�URY(ParaCdden!) S
HIED AUTOS X AUTOS
WNED PPROPERT`(DAMAGE $
$
UMBRELLA UAB OCCUR J��
EACr+oCS:l3RRP_NCE $
EXCESS LUU3 CLAIM&-MADE AGGREGATE $
TIED I I REMNTION $
_ WORKERS COMPENSATION x 1MG57ArU. OTH-
AND EMPLOYERS'UAINUTY YIN -.E4-
ANY PROPRJ TOWPARTNER/EXFOUTIVE NIA E.L.EACH ACCIDENT $ 500,000
OFFICEWMS;MgER EXCLUDED?
(MandamrylnNH) 939976603 1/1/2015 11/2016 IF DISEASE-EAEMP $ 500 000
If Yea,describe under
DEFCRIPTIONOFOFERATIONSbalow ELDMEA$E-POLICY LIMIT $ 500 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES(AWch ACORD 101,Add)tlonal Remarks Schedule,if mare space is required)
Operations usual to the sale & installation of doors & windows.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main St
Northampton, MA 01060 AUTHORIZEDREPRESENTATIYE
Judi Mabee/atl
ACORD 25(2010105) a 19W2010 ACORD CORPORATION. All rights reserved.
INS025(2oloos).oi The ACORD name and logo are registered marks of ACORD
Pella Products, Inc.
155 Main Street
Greenfield, MA 01301
Phone: 413-772-0153
To: Building Inspector
From: Al Herringshaw—General Manager
Date: December 31 st, 2014
SUBJECT: Building Permit Applications & Designees
Pella Products Incorporated is in the business of replacing windows and doors for our
customers. Our process includes providing a building permit for each and every project.
I am a licensed Construction Supervisor. Building permits will be applied for using my
CSSL#100235 and our HIC, # 142279. Please find a copy of my licenses below.
a Massachusetts-Department of Public Safety
Board Of Building Regulations and Standartis
C'onstructiOA Supervisor Special- Restricted To:cSSL-WS-Windows and Siding
License:CSSL-100235
ELWIN P HERRI)0, r`"f
34 DARTMOUTTIR
LONGMEADOgFM
11 w
r
r
Expiration
Commissioner 03114/201$ Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DFS licensing information visit: www.Mass.Gov/Di"s
� trice of Consumer Affairs&Business R eg aeon�I lion
License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date, if found return to:
e Office of Consumer Affairs and Business Regulation
gistration. 14��jg Type 10 Park Plaza-Suite 5170
1
Expiration";3r,24/2016 Supplement hard Boston,MA 02116
PELLA PRODUCTS;,A -'
ELWIN HERRINGSHAW .
155 MAIN STREET
GREENFIELD,MA 01301
Undersecretary Not valid without signature
Each installation will be staffed by our installers who are all licensed in accordance with
current building codes. Following are copies of their current licenses. Please accept
these individuals as my Designees:
Willard Brown CS106010 Vladimir Shevchuk CSSL099209
Scott Bowdish CSSL100232 Curt Boyle CS78514
Dave Ruffner CS57308 Bill Leger CS89338
Chris Gamache CS86946 Brian Thompson CS67121
Andy Kimball CS85981
If you have any question, please contact me using the numbers listed above.
C:\Users\0410SALESLAPI\AppData\Local\Microsoft\Windows\Temporary Internet
Files\Content.Outlook\075W4UO3\CSL-Designees 2015v1.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Pella Products, Inc.
Address: 155 Main Street
City/State/Zip:Greenfield, MA. 01301 Phone #:413-772-0153
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 49 4. K I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other Replacement Windows&Doors
employees. [No workers'
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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Hanover Insurance Group
Policy#or Self-ins. Lic. #:WHN-9399766-02 Expiration Date:01/01/2016
Job Site Address:7 Z {�Q�,(,tt 92 City/State/Zip: f �d
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 cer ify under th_ a pa'%ad n a ties of perjury that the information provided above iss�true and correct.
Si natur . Dater 7
Phone#: W ��-7&6
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#:
PELLA RODUCTS, INC.
155 MAIN STREET
GREENFIELD, MA. 01301
Date: (4 ' L Ll 1 ,5
!al f
Subject: Disposal of Debris
The purpose of this letter is to certify that all debris 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
Debris 06-17-14.doex
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: }� Not Applicable ❑
Name of License Holder: �u�In I'�-4y /Z q skA-,�" ess L t o-oa3S
License Number
<3 ,rit.7lt&WV� o d (/ o l0 3 - I Lt
Address Expiration Date
3 7 7�D/
Signature Telephone
�1. C
9.Reaistered Home Improvement Contractor: Not Applicable ❑
14aa-7 9
Company Name Registration Number
3 —aLf -- ! b
Address Expiration Date
Telephone
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 ........A. No...... ❑
Ho ne 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)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ED
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[O]
Brief Descriptign of Proposed ' �1 L� J� _ '- /-
Work:��?l w. St jf [.t/t1�
V
Alteration of existing bedroom Yes V"'No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes _ 40
Plans Attached Roll -Sheet
6a.If New house and or addition to existing ho using;:comylete 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 AS�),ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,- °���f 1. J (,ti �
, as Owner of the subject
property
hereby authorize Pella la 1,0 0 +s
to act on my behalf, ' all mattters rel v to work authorized by this building permit application.
Sig ature of Owner Date
as Owner/Authorized
Agent hereby declare that the stateme is 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.
Print N
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 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: _
4 e. _.a..,..,
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES �J
IF YES, date issued i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book " Page, and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO Q DONT 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, x vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
ipprtment use
ty of Northampton Stet s f rfr ft f
Q15 ilding Department t/rb� t� ewa�smrt
12 Main Street 5ewrptlottif
Room 100 w4t6d a v Il tlr +
Electric,Plumbing as Inspections MA 01060
Northampton,MA otoso No ampton, Two # ofS �trtallens
phone 413-587-1240 Fax 413-587-1272 Itlitet '�
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: // /
,--.v2 0 ��V/`{ e- ��1 Map Lot Unit
ep/ 623 Zone Overla y District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of pRecord:
Name(Print) Current ailin Addre
Telephone
Signature
2.2 Authorized Aaent:
cS
NamVPrint) Current Mailing Address:
j13 - 7-7-2 - () iS3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building D (a)Building Permit Fee
2. Electrical �w (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) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
582 HAYDENVILLE RD-Route 9 BP-2015-1002
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-1002
Project# JS-2015-001923
Est. Cost: $8000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 100235
Lot Size(sq. ft.): 32800.68 Owner: CORREA ARLENE&GORDON SHAW
zoning: SR(100,)/ Applicant: PELLA PRODUCTS, INC
AT: 582 HAYDENVILLE RD - Route 9
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON:412212015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 11 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 4/22/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner