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36-295 (4) 57 SOVEREIGN WAY BP-2017-0612 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-295 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Door Replacement BUILDING PERMIT Permit# BP-2017-0612 Project JS-2017-000990 Est.Cost: $7662.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(sq. ft.): 59459.40 Owner: GEORGE RICHARD N JR&KARIN L Zonine: Applicant: PELLA PRODUCTS, INC AT: 57 SOVEREIGN WAY Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 Liability GREENFI ELDMA01301 ISSUED ON:11/1/2016 0:00:00 TO PERFORM THE FOLLOWING WORK REPLACING 1 SLIDING PATIO 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 11/1/20160:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit. `auilding Department Curb Cut/Driveway Permit 2 Main Street saver/Septic Availability es\ Room 100 Water/WeiAvailability \,, �t8'o am ton, MA 01060 Two Sets of Structural Plans one 587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify PPEWw'c'ION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION IV- 6 ( 7-- /Z 1.1 Property Address: This section to be completed by office 51 JOVR-Pgl9n W0J Map Lot Unit FI„ru,(e- ,MR OIScl Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: (4orLl C-&orgc- 51 Sovercr3n k)aq ,Florence IIIA O1o(02 Name(Print) Cunt Mailing Address'. J f d J ,5 5 -- ({73-5810 1953 Telephone Signature 2.2 Authorized Agent: Trevor mss (Pella Products (nc) 65 Han , Gre&rte(ol , HA of 301 Name���Pring//// c///4 CuCurrentii� ent Mailing Address- � .iL /6 / a /1 p(13 773 /IS7 K V/Si Telephone SEC ON 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building e-krCrQ i N 3 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) • 5. Fire Protection ) 6. Total=(1 +2+3+4+5) 1(jCeQ, 43 Check Number 5 k 7&' *yo This Section For Official Use Only Building Permit Number: Date ///� sued: / Signature-�%i��� i //t! '45 Building Commissioner/Inspector of Buildings Date • Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning c _S � /QJ L _ 1 This column to be filled in by 4,x, ftp Wr')7�-1 Building Department Lot Size Frontage Setbacks Front Side L: R: L: Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parting) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding been issued for/on the site? NO O DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regist Deeds? NO O DONT KNOW YES l IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO l DONT KNOW YES l IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained l Obtained l , Date Issued: C. Do any signs exist on the property? YES O NO V IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO ©� IF YES, describe size, type and location: E. WII the construction activity disturb(clearing, grading, exca n,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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement W' ows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[D] Other[Cj Brief Dp,scription of Proposed Work: Keo)ac•ng 15) Lha pAt+o do0/ USIA �Sfi7 VA" wi 11, nn c.( ve5 k U-VA4R- CI.'1 i f � 9 j Igo 16C ng Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No t Attached Narrative Renovating unfinished basement Yes ✓ No c Plans Attached Roll -Sheet aa. 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: Num.-r of Ba ..ms c. Is there a garage attached? d. Proposed Square footage of new construct'. Dimen s e. Number of stories? f. Method of heating? Fire•aces r Woodstoves • Number of each g. Energy Conservation • ••••fiance. Mas- hec• Energy Compliance form attached? h. Type of construction • i. Is construction within 100 ft. of weban•.? es No. I- construction within 100 yr. Floodplain Yes No j Depth of basement or cellar Fl•or below finis' •r:de k. Will building conform to the Buil.' g 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. KCt OJ CA Geor5c ,as Owner of the subject property hereby authorize Pe r/��II4 I'rtuC'ILL J Iel(- to act on my behalf, in all hatters relative to work authorized by this building permit application. 1 J 6-Signature of Owner LL Date Ao/V%Lif% I, Pa& Pc-ado(7S Inc_ 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. ' r Bross Print Name S u of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 so Name of License Holder: TreFO( tyr>SS C.S-Gal GS S$ License Number to C.. -anni S4" Gree$ dra HA al3ol 3/l / (YS Address . Expiration Date 4,,,,,,, c WI-173- 1157 x 317 9.Registered Home Improvement Contractor: Not Applicable 0 f$(/y. Products Inc_ I 'aad -1c/ Company Name Registration Number 155 Hain S -" , brec-4 .e(CI rill 61301 -51a11i8' Add----- ��)) Expiration Date � TelephoneK(3'7 7],�r57 x ll 7 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 6 No 0 11. - Home Owner Exemption 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,oris 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,StateandL al Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature i\) / t City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: Si covet-e.,y„ W a,. , GlorcnK . NA The debris will be transported by: 1St I1a Prod,,rk3 /nc The debris will be received by: 155 (area y(o Nt A- 0i3c) Building permit number: Name of Permit Applicant Pella AWL.IA Inc. tTr%e- uDr 10/07 MO C y .� Date Signature of Permit Applicant Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Phone:413-772-0153 Cell: 413-834-8799 To: Building Inspector From: Trevor Bross—Installation Manager Date: February 23,2016 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 CSL#CS-096558 and my HIC# 182150. Please find a copy of my licenses below. 5 ac uset,S :acaro Bu',rg Raqt,:ato:is Stlr,aris Construction Supervisor Restricted to- ' 7-)730 CS-096558 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. TREVOR BROSS 10 GEORGE STREET - GREENFIELD MA 01301 t Failure to possess a current edition of the Massachusetts 03101121/18 State Building Curie is cause for revocation of this license. —- -- D_-- OPS Licensing information visit:WWW.MASS.GOV.'OPS —s=Oflce of Consumer Affin&Business Regulation License or registration valid for indlvidul use only before,_ ROME IMPROVEMENT CONTRACTOR Office of expiration tlma If found return to; Omce of Consumer Affairs and Bnaneas Regulation Registration: 142279Type: 10 Park Plays-Suite 5170 '"- Expiration: 3/24/2018 Supplement Card Boston,MA 02116 PELLA PRODUCTS.INC TREVOR BROSS 155 MAIN STREET GREENFIELD,MA 01301 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 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 John Joy CS004599 If you have any question,please contact me using the numbers listed above. ''VDATAFILES\Shared\INSTALLATTON\Pictures\CSL scans CSL-Designees 2015v1"riot • /� The Commonwealth of Massachusetts Weir { _ "1 Department of Industrial Accidents - - ', I Congress Street,Suite 100 �— Boston, MA 02114-2017 —` www.mass.gov/dia - S Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/OrganizatiaJIndividual):Folla 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): LEI l am a employer with 49 employees(ran and/or panaimel, 7. ❑New construction _ 1 am a sole propnetor or partnership and have no employees working for me in any capacity. No workers'comp_insurance required] 8. 9 Remodeling 3.0 I am homeowner doing all work myself.[No workers'comp_insurance required.]* 9, Demolition 4.01 am a homeowner and will be hirin O❑Building addition g commcmrs to conduct all work nn my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions pmpticrors with no cviploycos. 12.0 Plumbing repairs or additions SD l am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers comp.insurance/ 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152.I I(4),and we have no employees. No workers'comp.insurance required.] "Any applicant that checks box k I must also till out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they arc 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. lithe 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.`L -i le.#: WHN-9399766-04 Expiration Dater 01-01-2017 Job Site Address: 6 1 50✓CfPn"Th w°'`) City/State/Zip: Florence HS) (fl or,D Attach a copy of the workers'competl'sation polity declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 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. I do hereby c' r under the pains and penalties of perjury that the information provided above is true and correct Si nature: / . --- Date: 18 0 CD am— Phone#: Above 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#: e SRpCERTIFICATE OF LIABILITY INSURANCE OATE 1/7/2016D YYI 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,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 H2pEACT Robin Sargent Berkshire Insurance Group, Inc. FM,MO Eat: (913)993-9913 �NAAC No,14131774-3672 117 Main Street AEADDRSS:rsargentaberkshireinsurancegroup.COM INSURER15f AFFORDING COVERAGE HAICX Greenfield MA 01301 INSURER A Massachusetts Bay Insurance Co 22306 INSURED INSURER Et The Hanover Insurance Company 10212 Pella Products, Inc. INSURER C:_ 155 Main Street INSURERD: INSURERE: _. ......._..I Greenfield MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER:16GL.AL,WC 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. INSRI ADDL SU—Bar POLICY EFF POLICY EXP - -- - - LTR' TYPE OF INSURANCE INS0 WVq POLICY NUMBER OAMO0ryYW1 IMMNDNWYI LAIRS 1 X I COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000.000 I DAMAGE-ID RENTED 100,000 A 1 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ SNR941720204 1/1/2016 1/1/2017 I MED EXP( 10,000 J .__. . . . ____ I PERSONAL ADV INJURY S 1,000,000 GENSAGGRE�GATE LIMRAFPLIES PER'. I GENERAL AGGREGATE IS 2.000,000 POLICY' ac 11Eo- X LOC PRODUCTS-COMP/OPAGG S 2.000,000 1 OTHER: S AUTOMOBILE LIABILITY �LIED SINGLE LIMIT $ 1,000,000 A —1 ANY AUTO BODILY INJURY(Per person) $ - _ _ _... cAe AUTOS OOWNEO 6 AUTOS App9399]]009 1/1/2016 1/1/20ll BODILY INJURY amNenO $ NONOWNED PROPERTY DAMAGE I$ X I HIRED AUTOS X_ AUTOS (Pe,accident) .. 1 Is UMBRELLA OABI OCCUR I EACH OCCURRENCE I$ EXCESS UAB ( . I_ CLAIMS-MADE. i AGGREGATE $ DED RTENTKNS Is 1 WORKERS COMPENSATION i X I PER 1 27,* TH- �AXDEMPLOYERS'LIABLITY YIN STATUTE i ER ANY PR OPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 500,000 B OFFICER/MEMBER EXCLUDED? I A NIA (Mandatory NH) C ii MmT9399766 1/1/2016 1/1/2017 E.L.DISEASE- EMPLOYED $ 500,000 If yes.describe under 1 '- IDESCRIPTIONOFOPERATIONSbelowI E.L.DISEASE-POLICY LIMIT I$ 500,000 I I DESCRIPDON OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional R9mib Schedule.may be attached Snore 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 Town of Florence (Northampton) THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Building Commissioner's Office, ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St Northampt on, MA 01060 AUTHORIZED REPRESENTATIVE Robin Sargent/mils ' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 colon