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17A-185 (7)
173 NORTH MAPLE ST BP-2021-1269 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 185 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2021-1269 Project# JS-2021-002106 Est. Cost: $23733.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(sq. ft.): 7187.40 Owner: ERDMAN HARLEY M Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 173 NORTH MAPLE ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC GREENFIELDMA01301 ISSUED ON:5/3/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 13 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring U.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 Signaturel4L• >2 TIT FeeType: Date Paid: Amount: Building 5/3/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner /r f c �, The Commonwealth of Massac,husett �p9 �O Board of Building Regulations and Stan `9�� FCO AL ITY a Massachusetts State Building Code,780�`1 00, (91 �.� q y�0/4,, SE Building Permit Application To Construct,Repair,Renovate n Atig ' a Revi d Mar 2011 One-or Two-Family Dwelling 4414; N. �'�� Thiy�Section For Official Use Only Building l/ -/ermit Nutn -/Jo q Date Aplied:/ c:uawn, 41-3I.202.1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 113 j.)• MPrP1, ... $1 - NHAMM:o►7AB :OW5L : 0001 1.1 a Is this an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Pro esty Dimensions: ',5' Zoning Fxt57tJJG- ►Z.es1der.,-1-;A.t_ /7 / Y} Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1-1 A R .RM A.t vi EO AJ r�� U e vU Ce. MA. G ICU ?, Name(Print) City,State,ZIP 1 'T 3 is1. M A Pc.c_ ST' 413-32.o-actgl ,vo,u E No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other $1 Specify:Replete(&XI W teJPows Brief Description of Proposed Work2: R.e p Jo_a\t All L 13 ) o ?r.A.) t&)G S 1 ./JO 'I.p ci,ct•e.( Gh a Vl! Cr-C U �-AcTO 2.3 0 I- • 9.1 ) .a'7 . 30 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ c13 7 33 — 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ce 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ ie 2. Other Fees: $ 4. Mechanical (HVAC) $ pf List: 5. Mechanical (Fire $ �`" Suppression) Total All> �a.�(ees: , ) i-it Check No. eck Amoun : Cash Amount: 6.Total Project Cost: $ ci3 n 33 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) TR-EuorL -5 coss CS—og(� 55g 3-I -�oa� License Number Expiration Date Name of CSL Holder S List CSL Type(see below) V No.and Street � Description G-C �.,e-\a I /V A lH/1' 0 13o 1 Unrestricted(Buildings up to 35,000 Cu.ft.).)A Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 43- 51 -51 (ai ♦tiros%@pellaSgjeS.cowl I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ll0. ��udu�f t 1-t2.�19. 3-a3-and S J.. . HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name I S5 MPf t Ix) I ST ef_ � `i Ilagal�es.CON\ No.and Street Email address Gre,.e...,N e Id )b13o 1 1,Ii3-5la—S41.1 City/Town,State,ZIP / Telephone SECTION 6: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 No . ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize --Pe- I<0. +5 IA.)c. to act on my behalf;in all matters relative to work authorized by this building permit application. —1 a( 1 -e q 2 fa vv\ - s rN -off! -a:.I Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in 's a plication is true an a e to the best of my knowledge and understanding. <r Ll —a1 —a-1 Print Owner's Authorized Agent's Name lectronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Contract - Detailed 70Pella Window and Door Showroom of Greenfield Sales Rep Name: ® 240 Mohawk Trail Sales Rep Phone: Greenfield, MA 01301-3209 Sales Rep Fax: Phone:(413) 774-7231 Fax: (413) 774-6348 Sales Rep E-Mail: Customer Information Project/Delivery Address Order Information Harley Erdman Erdman Harley 173 N Maple St Florence MA Quote Name: Lifestyle series 1168923 173 North Maple Street 52 STORE 173 North Maple Street Order Number: 739W3EL041 FLORENCE, MA 01062 Lot# Quote Number: 13856663 Primary Phone:(413)320-2949 FLORENCE, MA 01062 Order Type: Installed Sales Mobile Phone: County: HAMPSHIRE Wall Depth: Fax Number: Owner Name: Payment Terms: C.O.D. E-Mail: na@na.com Harley Erdman Tax Code: MASS Contact Name: Owner Phone: (413)320-2949 Cust Delivery Date: 6/9/2021 Quoted Date: 3/26/2021 Great Plains#: 53H5860509 Contracted Date: 4/6/2021 Customer Number: 1002385281 Booked Date: 4/15/2021 Customer Account: 1000335779 Customer PO#: Customer Notes: Price includes removal of old products, new products,interior/exterior trim where necessary,installation,and building permit. Total-$23,733 for special 20%off discount. Lifestyle series fixed and casement windows. Double Hung in stairway. Bright white interior/White exterior. Pella Care Garuntee included(10 year labor warranty). New Fullview storm door. Home built in 1922. For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella®website at www.pella.com Printed on 4/16/2021 Contract-Detailed Page 1 of 13 Customer: Harley Erdman Project Name: Erdman Harley 173 N Maple St Florence MA Order Number: 739W3EL041 Quote Number: 13856663 Line# Location: Attributes 10 Office Lifestyle, 2-Wide Casement, 39.5 X 54.5,Without HGP,White Item Price Qty Ext'd Price $2,735.98 3 $8,207.94 'e 1:Non-Standard SizeNon-Standard Size Left Casement c-t Frame Size: 19 3/4 X 541/2 PK# General Information: No Package,Without Hinged Glass Panel,Clad,Pine,5",3 11/16" Exterior Color/Finish: Standard Enduraclad,White 15. @r$^?:ez" 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Wash Hinge Hardware, Fold-Away Crank,White, No Limited Opening Hardware, No Integrated Sensor Screen: Full Screen, Bright White, InViewTM Performance Information: U-Factor 0.29, SHGC 0.27,VLT 0.51,CPD PEL-N-14-00677-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50,Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: No Grille, Vertical Mull 1: FactoryMull, Standard Joining Mullion, Mull Design Pressure-20, Overall Thru Direction-Vertical 2:Non-Standard SizeNon-Standard Size Right Casement Frame Size: 19 3/4 X 54 1/2 General Information: No Package,Without Hinged Glass Panel,Clad, Pine,5",3 11/16" Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Wash Hinge Hardware, Fold-Away Crank,White, No Limited Opening Hardware, No Integrated Sensor Screen: Full Screen,Bright White, InViewTM Performance Information: U-Factor 0.29,SHGC 0.27,VLT 0.51,CPD PEL-N-14-00677-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50, Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: No Grille, Wrapping Information: No Exterior Trim,3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length = 188". Rough Opening:40-1/4"X 55-1/4" EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 LP-1 -Lead safe practices this opening Qty 1 MP-7-2 Wide Modified Pocket Installation Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella®website at www.pella.com Printed on 4/16/2021 Contract-Detailed Page 2 of 13 Customer: Harley Erdman Project Name: Erdman Harley 173 N Maple St Florence MA Order Number: 739W3EL041 Quote Number: 13856663 Line# Location: Attributes 15 Office Support Product, Direct Set Fixed Frame, 63.5 X 54.5,White Item Price Qty Ext'd Price $1,830.27 2 $3,660.54 °` 1:63.554.5 Fixed Frame Frame Size: 63 1/2 X 541/2 General Information: Interior Glazed, Factory Assembled,Standard,Clad, Pine,5",3 11/16" PK# Exterior Color/Finish: Painted,Standard Enduraclad,White 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Performance Information: U-Factor 0.27,SHGC 0.32,VLT 0.61,CPD PEL-N-18-02796-00001,Performance Class CW, PG 50, Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08111 Grille: No Grille, Wrapping Information: No Exterior Trim,3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length=236". Rough Opening: 64-1/4"X 55-1/4" PF-2-Exterior Pocket Installation Qty 1 EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 LP-1 -Lead safe practices this opening Qty 1 Line# Location: Attributes 20 Stairs Lifestyle, Double Hung, 25 X 44.5,Without HGP,White Item Price Qty Ext'd Price $1,896.60 1 $1,896.60 ,. III 1:Non-Standard SizeNon-Standard Size Double Hung,Equal Frame Size: 25 X 44 1/2 ILI PK# General Information: No Package,Without Hinged Glass Panel,Clad,Pine,5",3 11/16",Gray Exterior Color/Finish: Standard Enduraclad,White 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Cam-Action Lock,White, No Limited Opening Hardware,Order Sash Lift, No Integrated Sensor Screen: Full Screen,White, InViewTM Performance Information: U-Factor 0.30, SHGC 0.27,VLT 0.50,CPD PEL-N-35-00367-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50,Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: SDL w/Spacer,No Custom Grille,7/8",Traditional(3W2H/OWOH) Wrapping Information: No Exterior Trim, 3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length = 139". Rough Opening: 25-3/4"X 45-1/4" LP-1 -Lead safe practices this opening Qty 1 EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 PF-2-Exterior Pocket Installation Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella®website at www.pella.com Printed on 4/16/2021 Contract-Detailed Page 3 of 13 Customer: Harley Erdman Project Name: Erdman Harley 173 N Maple St Florence MA Order Number: 739W3EL041 Quote Number: 13856663 Line# Location: Attributes 21 Dining room Lifestyle, 2-Wide Casement, 51.5 X 54.5,Without HGP,White Item Price Qty Ext'd Price $2,855.59 1 $2,855.59 in 1:Non-Standard SizeNon-Standard Size Left Casement Frame Size: 25 3/4 X 54 1/2 General Information: No Package,Without Hinged Glass Panel,Clad, Pine,5",3 11/16" ,r PK# Exterior Color/Finish: Standard Enduraclad,White .F.7t4133 7.82 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Wash Hinge Hardware, Fold-Away Crank,White, No Limited Opening Hardware, No Integrated Sensor Screen: Full Screen,Bright White, InViewTM Performance Information: U-Factor 0.29, SHGC 0.27,VLT 0.51,CPD PEL-N-14-00677-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50,Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: No Grille, Vertical Mull 1: FactoryMull, Standard Joining Mullion, Mull Design Pressure-20, Overall Thru Direction-Vertical 2:Non-Standard SizeNon-Standard Size Right Casement Frame Size: 25 3/4 X 54 1/2 General Information: No Package,Without Hinged Glass Panel,Clad, Pine,5',3 11/16" Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Wash Hinge Hardware, Fold-Away Crank,White, No Limited Opening Hardware, No Integrated Sensor Screen: Full Screen,Bright White, InViewTM Performance Information: U-Factor 0.29, SHGC 0.27,VLT 0.51, CPD PEL-N-14-00677-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50,Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: No Grille, Wrapping Information: No Exterior Trim, 3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length =212". Rough Opening:52-1/4"X 55-1/4" EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 MP-7-2 Wide Modified Pocket Installation Qty 1 LP-1 -Lead safe practices this opening Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 4/16/2021 Contract-Detailed Page 4 of 13 Customer: Harley Erdman Project Name: Erdman Harley 173 N Maple St Florence MA Order Number: 739W3EL041 Quote Number: 13856663 Line# Location: Attributes 25 Living Room Support Product, Direct Set Fixed Frame, 21.5 X 31.25, White Item Price Qty Ext'd Price $1,281.08 2 $2,562.16 rs fi!r 1:21.531.25 Fixed Frame Frame Size: 21 1/2 X 31 1/4 PK# General Information: Interior Glazed, Factory Assembled,Standard,Clad, Pine,5",3 11/16" Exterior Color/Finish: Painted,Standard Enduraclad,White . 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Performance Information: U-Factor 0.29, SHGC 0.32,VLT 0.62, CPD PEL-N-18-02773-00001,Performance Class CW, PG 90, Calculated Positive DP Rating 90,Calculated Negative DP Rating 90,Year Rated 08111 Grille: No Grille, Wrapping Information: No Exterior Trim, 3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length = 106". Rough Opening: 22-1/4"X 32" EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 LP-1 -Lead safe practices this opening Qty 1 PF-2-Exterior Pocket Installation Qty 1 Line# Location: Attributes 30 Upstairs office Lifestyle, Double Hung, 31.5 X 45.25,Without HGP,White Item Price Qty Ext'd Price $1,807.64 4 $7,230.56 I■ ■■I 1•Non-Standard Double Hung, SizeNon-StandardSize D ubl Equal Frame Size: 31 1/2 X 45 1/4 PK# General Information: No Package,Without Hinged Glass Panel, Clad, Pine,5",3 11/16",Gray Exterior Color!Finish: Standard Enduraclad,White 2086 Interior Color/Finish: Bright White Paint Interior Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Cam-Action Lock,White, No Limited Opening Hardware, Order Sash Lift, No Integrated Sensor Screen: Full Screen,White,InViewTM Performance Information: U-Factor 0.30, SHGC 0.27,VLT 0.50, CPD PEL-N-35-00364-00001, Performance Class LC, PG 50, Calculated Positive DP Rating 50, Calculated Negative DP Rating 50,Year Rated 08111, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: SDL w/Spacer,No Custom Grille,7/8",Traditional(3W2H/OWOH) Wrapping Information: No Exterior Trim, 3 11/16", 5", Factory Applied, Pella Recommended Clearance, Perimeter Length= 154". Rough Opening: 32-1/4"X 46" LP-1 -Lead safe practices this opening Qty 1 EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 PF-2-Exterior Pocket Installation Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella®website at www.pella.com Printed on 4/16/2021 Contract-Detailed Page 5 of 13 DocuSign Envelope ID:EF598C73-2AFC-4DE3-8B99-8209EACECBF1 Customer: Harley truman rroiect Name: Harley Erdman-173 N Maple St Florence MA Order Number: 739W3EL041 Quote Number: 13856663 [Project Checklist has been reviewed Harley Erdman Brandon Langan Order Totals r-CtScIEr Viietilifne (Please print) ,.-12441a, Rep Name (Please print) Taxable Subtotal $14,432.94 tk', ` ibtai ltn, 13W'tUA.J01A, (,a.1tiyut Sales Tax @ 6.25% $902.06 ifaoM o4poai•oo. - cao1w ieA ♦o7 Customer Signature Pella Sales Rep Signature 4/5/2021 4/5/2021 Non-taxable Subtotal $8,398.00 Total $23,733.00 ,at®cuSigned by: Date Deposit Received $0.00 Retktti ''LtUA. Amount Due $23,733.00 ` 12ce•uoaaee•ee Credit Card Approval Signature For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 4/5/2021 Contract-Detailed Page 11 of 11 PELLA PRODUCTS INC. 155 MAIN STREET GREENFIELD, MA. 01301 Date: - -a_ To: WJ,! r� -f- I 0 f f vJC e_ 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; 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. Denise Chortler Accounting Manager Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Office:413-773-1157 Ext.317 Cell:413-834-8799 To: Building inspector From:Trevor Bross—Installation Manager Date: February 21, 2021 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# 142279. Please find a copy of my licenses below. Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted- ngs wit use soup Imo containBoard of Building Regulations and Standards less than 35 000 cubic feet(p01 cubic meters)of Mifdosad C o nat isor CS-096558 $ firett:03f01l2022 TREVOR : -', v 10 swam ;;a ^, c t3RELr Failure to possess a current edition of the Massachusetts 41 .'J ,4 ' State Building Code is cause for revocation of this license. , COMMISSIONS,; � � �a� . For information about this license ` Call(617)727.3200 or visit www.mass.gov;dpf .Tk Viir>i,wseri Nlxfl'�el.l?i,743 MtsdP//� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration fjwiration Office of Consumer Affairs and Business Regulation 142279 03/23/2022 1000 Washington Street -Suite 710 1 PELLA PRODUCTS,INC. Boston,MA 02118 ELWIN HERRINGSHAW % Ci P ,t/e 155 MAIN STREET Nita ;' 4a€ GREENFIELD,MA 01301 Undersecretary Not valid without signs Each Installation will be staffed by our installers who are all licensed in accordance with current building codes. Below listed are our installers and their license numbers. Please accept these individuals as my designees. Willard Brown CS106010 Vladimir Shevchuk CSSL099209 Scott Bowdish CSSL100232 Bill Leger CS89338 Christian Lambert CS065102 Robert Kairnes CS113305 Igor Kravchuk CS094911 :\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center Ci-k . 1'1 2 Avenue de Lafayette, Boston,MA 02111-1750 '� ��• 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. ■❑ I am a employer with 50 4. Q 1 am a general contractor and 16. El New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. • Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §I(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: EMC INSURANCE COMPANIES Policy#or Self-ins. Lic. #:6H15382 Expiration Date::01-01-2022 Job Site Address: i 1 3 ✓N. Mo,p 1e S+ City/State/Zip: --Y 1 p{ eVUCe )A! U 1 O10 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 certi n r the pains penal s of perjury that the information provided above is true and correct Signature: l Date: ' � —a Phone#: 1 3 ` Jr i s - 5 R LP T. Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License #_. Issuing Authority(check one): I❑Board of Health 2❑Building Department 3.0City/Town Clerk 4.0 Electrical Inspector 5E1Plumbing Inspector 6.0Other Contact Person: Phone#: PELLPRO-01 CHRISTINE ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/21/2020 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 have ADDITIONAL INSURED provisions or 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 CONTACT Christine Sullivan NAME: Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (NC,No.Ezt):(413)594-5984 (Jc,Nam:(413)592-8499 Chicopee,MA 01013 n DRESS:Christine©phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:EMC Insurance Companies 21415 INSURED INSURER B:Union Insurance Co of Providen Pella Products,Inc INSURER c 155 Main St INSURER D: Greenfield,MA 01301 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR I ADDL SUER POLICY EFf POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER 4MMIDD/YYYYI IMMIDD/YYYYL LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 6A15382 1/1/2021 1/1/2022 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 aa POLICY X JECT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO 6215382 1/1/2021 1/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSONLY AUTOS yry BODILY INJURY(Per accident) $ AUTOS ONLY S yONLY (Per PROPERTY DAMAGE $ - A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS UAB CLAIMS-MADE 6J15382 1/1/2021 1/1/2022 AGGREGATE $ 4,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY YIN H 6H15382 1/1/2021 1/1/2022 500,000 ANFICRWM�MOR/EXCLU�ED7ECUTIVE n, NIA E.L.EACH ACCIDENT $ (Mandatory m NH) _E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Installation Floater$50,000 Included Operations usual to the sale and installation of doors&windows. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Florence(Northampton)BuildingCommissioner's THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ( P ) ACCORDANCE WITH THE POLICY PROVISIONS. Office 212 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD