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38B-269 (7) 242 SOUTH ST BP-2016-1553 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-269 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-2016-1553 Project# JS-2016-002656 Est. Cost:$3249.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Collat.Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(sq, ft.): 7056.72 Owner: WULSIN COURTNEY HILL 7onit iUR8(I00V Applicant: PELLA PRODUCTS, INC AT: 242 SOUTH ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC G R E E N F I E L D MA 01301 ISSUED ON:6/29/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACING 1 DOOR USING EXISTING OPENING 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: Cas: Fire Department Fireplace/Chimney: Rough: O_ 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 6/29/20160:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 1vi" ieslT 1 sa . City of Northampton 4r) { /71 Building Department ( l r 212 Main Street � �� Room 100 ^� r -.� 7C-11 `' Northampton, MA 01060 / phone 413-587-1240 Fax 413-587-1272 !: r r •.� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S -CTION 1 •SITE INFORMATION a t,5 ,r g tl ObSgrOpleted by office 1.1 Property Address: f �y a �,0,3�'h Sl— t'A'a f Ldt Unit ftorWw 1 rn/s .: � G11t7te0 44e' oviir(aZolatrlot Stell33Middt;,, - CS,District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2. • e.:. • Rec•rd: 1 �} ILS— L ' �Ak i Oi T " N' S` 1 b`i ..,r; t L • Name(Pd Current Maili Address: X1,3 . 413- .v., — Telephone Signature 2.2 Authorized Anent: 1 ,._ j' ��/r c\k. crYYIi . -�n c 155 rrr, rn �j. 4TP•PPn9eid /Yja Name sir Current Mailing Address: O13<)i r t/l3 113 //51 Signatu Telephone SECTIONS-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building =) a g ' (a)Building Permit Fee 2. Electrical J ,,, (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) a a q7 0v Chock Number 5'7(./ # "GQ This Section For Official Use Only Building Permit Number: Date Issued: Signature: __ Buildrig Commissionertinspector of Buildings Date Section 4. ZONING Al(Information Must Be Completed.Permit Can Be Deified Due To incomplete information .xisting' Proposed Required by Zoning This column to be filled in by 'Rees t{itt 1tTTJ i D Building Department Lot Size _____________ ] i Frontage 1..._. —_.._. -. r______--_..J ---- ---- Setbacks Front L. ) r� Side L:1-11 Rt-11-21 L:IR: En I__...] Roar 1__ ;_____1 Building Height { L_.J Bldg.Square Footage —'i =3 /o ELI] Open Space Footage % (Cat area minus bldg&paved 7 C_.�� C..� ( [ t L. 1 parking) tt of Parking Spaces 1 I Fill: r — 77 a __ vlue&Location) L. _ -- --------A. Has a Special Permit/Variance/Finding ver been issued for/on the site? NO © DONT KNOW ` YES IF YES, date issued: ' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES O IF YES: enter Book I I Page j and/or Document e B. Does the site contain a brook, body of water or wetlands? NO 0/ DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES CI NO 01/ IF YES, describe size, type and location: ? D. Are there any proposed changes to or additions of signs intended for the property? YES C> NO (D IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading exca ation,or filling)over 1 acre or is it part of a common plan that will disturb over I acre? YES a NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House E] Addition [] Replacement Windows Alteration(%) O Roofing ED Or Doors Accessory Bldg. Fl Demolition n New Signs [ni Decks ID Siding f0] Other IC] Brief Description of Proposed -Pelpk.-Ct I deed' 05'r1/ ei.s .- 5Pena 5 . xr, N0 Work.-_SAY.Lnys ibv.;dinst '5.7Prtm-i.vP ,. "77+a Lr tr.-r.A -,'_c0t30 Ge Lea Alteration of existing bedroom Yes - No Adding new bedroom Yes "/No Attached Narrative Renovating unfinished basement Yes Plans Attached Roll -Sheet cide 1i4S � r,t , -tair ;61 tri �'st �� i otin J' ,3.,;«1 -i: rt., N;fo','".ta: 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT qtr + Mb is `S / , as Owner of the subject property V /11 hereby authorize eeS [ or cutho z.i rt; to act on my behalf,in all matters relative to work authorized by this building permit . •pii - on. Paw TeAra.,,Rec x,..x,±} , tyre ?^ ort.)5S.) , 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. eC✓et^ -4.).rc.SS Print Name !/ ! _ 4 _ St:+j+j of Owner/Agent ^" Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: I reyp e' CSs^C'!SS CS, 0 /055 ((�� �! License Number /0 et Sryrerni ctd tW n Ol aA 03 Q/ pz Address Expiration Date Sig A'p1plicabllee�❑� -eel L. T rV'{LU+) -1a1C 1T elc3-79 Company NameRegistration Number tS.5 .rn V Grrnfigeld Ms nn361 031c>gf tau Address 4)3 Expiration Date Telephone 7/3•ln51 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,O.L.C.182, 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 R7 No 0 The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 betshe shall be responsible for all such work performed under the bulldina permit. As acting Construction Supervisor your presence on the job site will he 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 Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Phone:413-772-0153 Cell:413-834-8799 To: Building Inspector -C rr62-1 1 >t'/y tikr<452,' From: Trevor Bross—Installation Manager I- (} Date: February 23,2016 .—t-�lross1. ,ill. wI1c_pass- ('Orvl 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. 1 am a licensed Construction Supervisor. Building permits will be applied for using my CSL#CS-096558 and my FIIC it 182150. Please find a copy of my licenses below. 9 Massachusetts Department of Public Safety • Board of Building Regulations and Standards Construction Supervisor cense. Restricted to: CS-096558 less th n 35-Buildingsof any use group which contain cher ;ueeresor less than 35,000 cubic feet(991 cubic meters)of enclosed space TREVOR GROSS t GREENFIELD ENFIELSMA at ru, ,� 10GRSTREET ET -.�i• 3.. 1 ' Fawn.to possess a current edition of the Massachusetts rssmer _ 2018 State Building Code is cause tor revocation of this license. I}I 031fuer - WS lrerning information vtsq:VNMMASS.GOVt0P5 -m`-.0irice of Coasmer&Mks&Bagnen Rtgufs50n License or registration vale for individal use only wriom E IMPROVEMENT CONTRACTOR briereffieexpirada°date. V found return to: !r Office of Consumer Affairs and nusincss Regulation . ' Regi tnaon i4fl7e Type: IP Park-Pima„Suite 5i7e 'tr- Expiration: 32412018Supplement Card Boston,MA 02116 PELLA PRODUCTS.INC. TREVOR STOSS ,. 155 MAIN STREET 0, ••r — _. - t3REENMELD,MA01301 < Not valid without signature Undersecretary _ 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 individonis as my Designees: Willard Brown CS106010 Vladimir Shevchuk CSSL099209 Scott Bowdish CSSL100232 Curt Boyle CS78514 Dave Ruffner CS57308 Bili Leger CS89338 Chris Gamache CS86946 Brian Thompson CS67121 Andy Kimball CS8598I John Joy CS004599 If you have any question,please contact inc using the numbers listed above. \\DATAFILES\Shared\INSTALLATION\Pictures1CSL scans\CSL-Des;nees 2015v1.doc A OR S CERTIFICATE OF LIABILITY INSURANCE RATEIMMARDNYYY) 4lu 1/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(&), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED,the policy{ies)must be endorsed. R SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:`" Robin Sargent Berkshire Insurance Group, Inc. PHONE 1AR:.No.&tl (913)773-9913 P'IZ IAK tlol: 41a) ,74-36n 11? Main Street .DMFS6.rsargentOberkahireinaurancegroup.con INSURERIS)AFFORDING COVERAGE HAIL X Greenfield MA 01301 moires A Massachusetts Bay Insurance Co 22306 _ —AAAA .,�_.. INSURED IN6URE0.IS:The Hanover I6BllraACe Company_ 10212 Pella Products, Inc. INSURER C: 155 Main Street INSURERD: INSURER E: .- - - - Greenfield NA 01301 INSURERS: COVERAGES CERTIFICATE NUMBER:16GL,AL,RC REVISION NUMBER: THIS IS 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 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 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE bFINSURANCE � PODICYfii POLICY E%h UNITS lgn INSD MO POLICY NUMBER IMMND/fYYYI IMMND/YYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 (—i DAMAGE TORa' ED 100,000 A CLAIMS-MADE j_E_f OCCUR PREM ES Ea c4)) 3 SIm942720204 1/1/2016 1/1/2017 MED EXP(Myon Pasant S 10,000 PERSONAL 8MV INJURY S 1,000,000 GEN'L AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE 3 2,000.000 ._ POLICY 1 X;dECT I E • Lot - PRODUCTS. 2,000,000 COMPIDP AGO,i S I OTHER; AUTOMOBILE LIABILITY { ,,sNEml IN4LE LIMIT E 3.000,000 r_`ANY AUTO ALL BODILY INJURY IPA Person) i A LOWNED SCHEDULED N939977004 1/1/2016 1/1/2017 ,_ AUT06 x � ADBODILY INJURY War accident) 3 AUT X HIRED AUTOS X AUTOS D IPOPERTYD DAMAGE 5 — E I 010am, CCURRENCE E 4 uAa OCGua EACH O EXCESS LMB )CLAIMS-MADE AGGREGATE S DED I BEurrogi S $ WORKERS COMPENSATION E :STATUTE ER„ AND EMPLOYERS'LIABILITY y/N -- ANYPiOFRIETOWPARmEICExECUnVEN/A EL EACH ACCIDENT $ 500,000 B (Maarkwory In NH)ER CSCLUCEU" iN Wmpyb99766 1/1/2016 1/1/201> El DISEASE-EA EMPLOYEES 500,000 HdesdQe under OESSCRIPnON OF OPERATIONS below EL.DISEASE-POLICY LIMIT I3 500.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 10Y,Additional Remarks Schedule,may be MMMed II more space Is required) Operations usual to the sales and installation of doors and windows. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 212 Main St ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 AUTHORIZED REPRESENTATIVE ..,/ _.mss . Robin Sargent/RMS <_ ,; y .„ .55-2,e-/— s _ f5 1988-2016 ACORD CORPORATION. All rights reserved ACORD 25(2016/01) The ACORD name and logo are registered marks of ACORD 1145025 2(>1401) The Commonwealth of Massachusetts '—ac'? urL Department of Industrial Accidents 7--11051–a. 3 1 Congress Street,Suite 100 a .4 _ _ Boston,MA 02174-2017 :,yra� www.mass.gov/dia Workers'Compensation Insurance Affidavit:BnilderstContractorsIElectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organisation1ndividuai)'Pella Products, Inc. Address: 155 Main Street City/State/Zip: Greenfield, MA. 01301 Phone#:413-772-0153 Are you an employer?Chock the appropriate box: Type of project(required): 1.01am i employer with 48 - employees(roll and/or part-time)• 7. 0 New construction 2.❑[am a sok pop ietoror partnership and have no captoycca working forme in 8. 0 Remodeling any oapaciy.No workers'comp.insurance requucd.l 9. {,.,�Demolition 3�r am a homeowner doing all.work myself[No workers'comp.insurance rc1uired.l t 4.❑Iant a homeowner and will be hiring contractors to conduct all work on my pmpeny. 1will 10 Building addition ensutc that all contractors either have workers'compensation insumae or are sole 11.0 Electrical repaint or additions proprietors with no employees. I2.p Plumbing repairs or additions i am a general contractor and t have hued the sub-contractorslisted on the attached sheet. u ROOF repairs These subcontractors have employees and have workers'comp.insurance? 6 E We are am tion and its officers have exorcised theirn t of14.QOrher_ corporation gh exemption per MGL G. 152,11(4),and we have n employees[Nb workers'camp.iusnnnro'Nuled.) 'Any applicant that checks box must also fill out the section below showing their walkers'compensation policy information. 'Homeowners who submit this affidavit indicating they arc doing all work and then hire outside coMrac•ws must submit a new affidavit indicating suck ;Contractors that chock this box mast attached an additional beet showing the name of the sitexnnaetors and stale whether or not those entities have employees. lithe sub contractors have employees,they rust provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name: Hanover Insurance Group Policy#or Self-ins.Lic.#: WHN-9399766-04 _ Expiration Date: 01-01-2017 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 MOL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: ,.,: �,m_. ... Pate: rtlyera J/ Phone#: Abo e r 7 I Oficial use only. Do not write in this area,to be completed by city or town official City or Town:_ PermitRacense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone it: PELLA RODUCTS,INC. 155 MAIN STREET GREENFIELD, MA. 01301 Date: 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 Pmducts„ Inc. isunder 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 docx Contract - Detailed Pella Window and Door Showroom of Greenfield Sales Rep Name: Lukomski, Adam 240 Mohawk Trail Sales Rep Phone: (413)335-3237 Greenfield, MA 01301-3209 Sales Rep Fax: 413-774-6348 Phone: (413) 774-7231 Fax: (413) 774-6348 Sales Rep E-Mail: alukomski@184.pellapdsn.com Customer Information Project/Delivery Address Order Information Wulsin Courtney Wulsin Courtney 242 South St Northampton MA Quote Name: 1733291 Entry Door413-303-1246 242 South St 242 South St Order Number: 739P2GL071 NORTHAMPTON,MA 01060-4112 Lot# Quote Number: 7907475 Primary Phone:(413)3031246 NORTHAMPTON,MA 01060-4112 Order Type: Installed Sales Mobile Phone: County: HAMPSHIRE Payment Terms: C.O.D. Fax Number: Tax Code: MASS E-Mail: courtney.a.hill@gmail.com Quoted Date: 5/31/2016 Great Plains#: 53H3201640 Customer Number: 1007079161 rrn4-1a l( Ad-e ? Customer Account: 1002762873 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 6/22/7016 rnntrnrt-noroeon r.