02-024 (3) The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
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
Na2T10 (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.FM I am a employer with 49 4. I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑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. F-1 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ 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: City/State/Zip: 4c i o'er;_A
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 certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: r Date: r��
Phone#: -*;3 jZ 2--)2 3<j -4- ¢ 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#:
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.
Massachusetts-OePartment of Public Safety
Eloard of Building Regulations and Standards
Construction Supers isor Specialtt Restricted To:cssL-WS-Windows and Siding
License:CSSL-100235
ELWIN P HERRIyC w
34 DARTMOUTH'
LONGMEADOV►y
�f Corc usss 03/14/2016 Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
_ For DPS Licensing information visit: WWW.Mass.Gov/DP5
T
n�li��nrromcwrtcecclfLr r�C�1��,crtS.Sa�erzn(Y,t�
ice of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
egistration: 142279 Type 10 Park Plaza-Suite 5170
Expiration: 3/2412016 Supplement -3rd Boston,MA 02116
ffi 6
PELLA PRODUCTS,INC..
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 CSSLI00232 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\09SALESLAP2\Documents\CSL&HIC License Copy AI Herringshaw.doc
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aRRIicable)
New House Addition ❑ Repiacement Wows Alteration(s) Roofing
Or Doors ($$
Accessory Bldg. ❑ Demolition ❑ New Signs (D] Decks [Q Siding[❑] Other J 0
Brief Description of Proposed "
Work
Alteration of existing bedroom Yes_ .� No Adding new bedroom Yes V, No —
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
6a.If New house 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? FlrepVaces 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
I 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. Tom L�1 to Pi rj as Owner of the subject
property
hereby authorize
act y behalf, in all Items relative to work authorized by this bui ing perm i application
of Owner Date
OJ. ^,l(c: i .c"/s 14w- l H yh s Owner/Authorized
Agent hereby declare that the statements arif information on the foregoing application are true and acc to the best of my knowledge
and belief.
Signed under t e pains and penalties of perjury
Print Name g"'�"�'�c1+,-rL
L it
Sign,ture of Ovmer/Agent pate
tarm,ent use oni y
City of Northampton Stew
Building Department � �
212 Main Street
j , N►AY 18 Room 100 wadrl��►v> ►
N Irthampton, MA 01060 TWO Sets of S�tei#ft
Electri9E02tt
`� 4587-1240 FaX 413-5$7-1272 littow PItt is
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 g
�r� J s' f� L Map Lot Unit 1
�(f;114 VLC-lp- I 2 zone Overlay District
Etm 3L District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0 LAr
Name(Pn Current Mailing Addre
el I Telephone Ir
Signature
2.2 Authorized Anent: l]
Name(Pnn&:;;P_ Current Mailing Address L -"—i
Sigriature J� l
Telephone
SECTION ESTIMATED CONSTRUC T
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1 Building (a)Building Permit Fee
OCr�
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) ! C�ic� Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued
Signature
Building Commissioner/Inspector of Buildings Date
597 NORTH FARMS RD BP-2015-1137
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 02-024 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-1137
Project# JS-2015-002140
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.): 287931.60 Owner: QUINN THOMAS E&ANN H
Zoning: WSP(102)/RR(100)/WP(6)/SR(2)/ Applicant. PELLA PRODUCTS, INC
AT. 597 NORTH FARMS RD
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON.511912015 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 5/19/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner