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23A-239 (3)
2 POMEROY TERR UNIT COMMONWEALTH OF MASSACHUSETTS BP-2021-1782 7 Map:Block:Lot:32A-239- CITY OF NORTHAMPTON 007 Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1782 PERMISSION IS HEREBY GRANTED TO: Project# Contractor: License: Est. Cost: 18630 Const.Class: Exp.Date: Use Group: Owner: MILLER DORIEN and JEFFREY ZESIGER Lot Size (sq.ft.) Zoning: URC Applicant: PELLA PRODUCTS, INC Applicant Address Phone: Insurance: 155 MAIN ST (413)772-0153 GREENFIELD, MA 01301 ISSUED ON:08/24/2021 TO PERFORM THE FOLLOWING WORK: INSTALL 5 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. Signature: I• 7-1 I S Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 16 VED The Commonwealth of Massachusetts , Auy, Board of Building Regulations and Sean `ds Z 3 ��2� UNI FAR( IPALITY ��i Massachusetts State Building Code, 180 , ,'r fk r, SE Building Permit Application To Construct, Repair, Renovatd_p1 ��yy��o-k� T� evis d Mar 2011 One-or Two-Family Dwelling t-- r�'''�'oso s This Section For Official Use Only Building Permit Number: '• 1 .. l.73 Z- Date Applied: I a II 1 it ' `S' i \ .) A.. ,. . • i Building Official(Print Name) Signature I j Date SECTION 1: SITE INFORMATION 15ro rty Address: 1.2 Assessors Map&Parcel N li bers 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ec:'ccr-•„N r-ea`ct_SirlihctiL 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:j:s tA.. R �c4 ivv hr r, (Cv 0 I�1� Q Nam Print) City,State,ZIP r Ter_./ + 4/5 3 zo /5 3 v j OlLin r�&cor►-,cu✓Aive.'�' No.and S reet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': V.Uk rNa..p.,4, ,k 04— 5 vc(J\-, wanclw� Ope SOICi 1 l�v c aN.c-s �. \Ow:\CM(\ . o.Our- —29 I SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ r 8(030 0 a 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ / Check NoTn t r i heck Amount: 1 U Cash Amount: Q 6.Total Project Cost: $ I U t 3 0, 0 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS' Dat9S58 31 /aa- -�--e\juY �SS License Number Exp. ation Date Name of CSL Holder i O befirC S"1--. List CSL Type(see below) No.and Street 1,,' e Description \ Unrestricted(Buildings up to 35,000 cu.ft.) TI W. \3 Restricted 1&2 Family Dwelling City own,State,ZIP )�� M Masonry RC Roofing Covering WS Window and Siding 9y 1 �, / '�" SF Solid Fuel Burning Appliances 13 ` 7 . v)si/ y3/7 PWd5) ((k1 iles.CGA'1_- I Insulation Telephone Email address D Demolition 5.2 istered Home/ImprLLove nt Contractor(HIC) /y a� 9' I( a U U(is iA C ' HIC Registration Number pirati n Date H1C oq /I�any Ntune or HIC egis ant Name /55 & are SI—. peri iW- i� l/aiSa,les. t ii4j No. Street D(C, '^n Q 0 13 U/ y(3.77-a 0 l f3 email address Ci own,wn State,ZIP'l YY l`I Telephone )( l t 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 Issu nce of the building permit. Signed Affidavit Attached? Yes No .0 SECTION 7a:OWNER/AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Pella M 1u(kJ- i c., . to act on my behalf,in all matters relative to work authorized by this building permit app ication. S-<-12_ Gt14— Li• g ---* li - g/ 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 this application is true and accurat to the best of my knowledge and understanding. ? • Li I ..,. / _ _ Print Owner s or thorized Agent's Name(E me ignate) 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" DocuSign Envelope ID:34CE7D89-8D6A-4A1B-AD16-36E921B9AAC9 Contract - Detailed Pella Window and Door Showroom of West Springfield Sales Rep Name: Lukomski,Adam ® 69 Ashley Avenue Sales Rep Phone: (413)335-3237 West Springfield, MA 01089 Sales Rep Fax: 413-774-6348 Phone: (413) 736-9239 Fax: (413)736-3390 Sales Rep E-Mail: alukomski@pellasales.com Customer Information Project/Delivery Address Order Information Jeffrey Zesiger Zesiger Jeffrey 2 Pomeroy Ter Apt 7 Northampton Quote Name: Architect and Reserve 413-320-1530 2 Pomeroy Ter Apt 7 2 Pomeroy Ter Apt 7 Order Number: 739W2GL031 NORTHAMPTON,MA 01060-3351 Lot# Quote Number: 14015383 Primary Phone: (413)3201530 Northampton,MA 01060-3351 Order Type: Installed Sales Mobile Phone: County: Payment Terms: Fax Number: Tax Code: MASS E-Mail: jazmd@comcast.net Quoted Date: 4/29/2021 Great Plains#: 1005275077 Customer Number: 1009201203 Customer Account: 1005275077 Line# Location: Attributes 10 Bedroom Pella®Reserve, Traditional, Direct Set, Fixed Frame Gothic Springline, 29.25 X 69, Item Price Qty Ext'd Price Radius = 25-3c White $3,893.90 1 $3,893.90 I 1:Traditional,29.2569 Fixed Frame Direct Set Gothic Springline PK# Frame Size: 29 1/4 X 69 X 46 • 2089 General Information: Interior Glazed,Standard,Clad,Pine,5",3 11/16" • Exterior Color/Finish: Painted,Standard Enduraclad,White • Interior Color/Finish: Bright White Paint Interior Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Performance Information: U-Factor 0.29,SHGC 0.32,VLT 0.62,CPD PEL-N-18-02773-00001,Performance Class CW,PG 45,Calculated Positive DP Viewed From Exterior Rating 45,Calculated Negative DP Rating 45,Year Rated 08111 Grille: No Grille, Wrapping Information: No Exterior Trim,3 11/16",5",Factory Applied,Pella Recommended Clearance,Perimeter Length=179". Frame Size:29.25"X 69" Customer Notes: SPRAY FOAM WEIGHT POCKETS MP-4-1 Wide Modified Pocket Installation Qty 1 LP-1 -Lead safe practices this opening Qty 1 AC-9B3-OTHER-3 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 6/4/2021 Contract-Detailed Page 1 of 9 DocuSign Envelope ID:34CE7D89-8D6A-4A1 B-AD16-36E921 B9AAC9 Customer: Jeffrey cesiger rroject Name: Zesiger Jeffrey 2 Pomeroy Ter Apt 7 Northampton Order Number: 739W2GL031 Quote Number: 14015383 Line# Location: Attributes 15 Bedroom Architect, Traditional, Replacement Double Hung, 25.25 X 40.75,White Item Price Qty Ext'd Price $1,880.96 2 $3,761.92 1:Traditional,Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 25 1/4 X 40 3/4 2089 General Information: Standard,Style,Clad,Pine,4 3/4",3 1/4" Exterior Color/Finish: Painted,Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior Sash/Panel: Ogee,Ogee,Standard,No Sash Lugs Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Spoon-Style Lock,Oil Rubbed Bronze,No Window Opening Control Device,No Limited Opening Hardware,No Sash Lift,No Integrated Sensor Screen: Full Screen,Standard EndureClad,White,Standard, InViewTM Performance Information: U-Factor 0.29,SHGC 0.28,VLT 0.53,CPD PEL-N-233-00253-00001,Performance Class CW,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,Pella Recommended Clearance,Perimeter Length=132". Frame Size:25.25"X 41.4843" Customer Notes: SPRAY FOAM WEIGHT POCKETS PF-1WP-Interior Pocket Installation with weight pockets Qty 1 LP-1 -Lead safe practices this opening Qty 1 AC-9B3-OTHER-3 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 6/4/2021 Contract-Detailed Page 2 of 9 DocuSign Envelope ID:34CE7D89-8D6A-4A1B-AD16-36E921B9AAC9 customer: ,,enrey cesiger rroject Name: Zesiger Jeffrey 2 Pomeroy Ter Apt 7 Northampton Order Number: 739W2GL031 Quote Number: 14015383 Line# Location: Attributes 20 Bedroom Architect,Traditional, Replacement Double Hung, 31.25 X 49.25,White Item Price Qty Ext'd Price $2,025.78 1 $2,025.78 1:Traditional,Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 31 1/4 X 49 1/4 Qi it2089 General Information: Standard,Style,Clad,Pine,4 3/4",3 1/4" Exterior Color/Finish: Painted,Standard Enduraclad,White Interior Color/Finish: Bright White Paint Interior i Sash/Panel: Ogee,Ogee,Standard,No Sash Lugs Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Spoon-Style Lock,Oil Rubbed Bronze,No Window Opening Control Device,No Limited Opening Hardware,No Sash Lift,No Integrated Sensor Screen: Full Screen,Standard EnduraClad,White,Standard,InViewT'" Performance Information: U-Factor 0.29,SHGC 0.28,VLT 0.53,CPD PEL-N-233-00253-00001,Performance Class CW,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,Pella Recommended Clearance,Perimeter Length=161". Frame Size:31.25"X 49.9843" Customer Notes: SPRAY FOAM WEIGHT POCKETS PF-1 WP-Interior Pocket Installation with weight pockets Qty 1 LP-1 -Lead safe practices this opening Qty 1 AC-9B3-OTHER-3 Qty 1 Line# Location: Attributes 25 Kitchen Pella®Reserve,Traditional, Double Sliding Door,Vent Right I Fixed, 83.25 X 95.5, Item Price Qty Ext'd Price Eldridae Gray $10,921.37 1 $10,921.37 1:Traditional,8496 Vent Right I Fixed Double Sliding Door ii) PK# Frame Size: 83 1/4 X 95 1/2 �f7 e* 2089 General Information: Factory Assembled,Standard,Clad,Pine,5 7/8",4 9/16",Oak Threshold CT) Exterior Color/Finish: Painted,Standard Enduraclad,Eldridge Gray Interior Color/Finish: Early American Stain Interior I Sash/Panel: Ogee,Ogee,Standard - Glass: Insulated Dual Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Viewed From Exterior Hardware Options: Black,Standard,Handle Included,Handle Included,Oil Rubbed Bronze,Eldridge Gray,No Integrated Sensor Screen: Sliding Screen,Wood Interior Color Matched Exterior,Oil Rubbed Bronze,InViewTM Performance Information: U-Factor 0.29,SHGC 0.23,VLT 0.42,CPD PEL-N-237-00727-00001,Performance Class LC,PG 60,Year Rated 11 Grille: No Grille, Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,4 9/16",5 7/8",Factory Applied,Pella Recommended Clearance,Perimeter Length=358". Frame Size:83.25"X 95.5" For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 6/4/2021 Contract-Detailed Page 3 of 9 DocuSign Envelope ID:34CE7D89-8D6A-4A1B-AD16-36E921B9AAC9 customer:Jeffrey cesiger rroject Name: Zesiger Jeffrey 2 Pomeroy Ter Apt 7 Northampton Order Number: 739W2GL031 Quote Number: 14015383 [Project Checklist has been reviewed EJeffrey Zesiger Adam Lukomski Order Totals Customer Name (Please pent) Pella Sales Rep Name (Please print) Dom'Signed by: -Docusigned by: Taxable Subtotal $11,885.18 Qtiztai DStI Sales Tax @ 6.25% $742.82 7l? tl ii4Signature Signature 6/4/2021 6/4/2021 Non-taxable Subtotal $6,002.00 Total $18,630.00 Do Date Date Date Deposit Received $9,315.00 Amount Due $9,315.00 neernttiMenbApproval 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 6/4/2021 Contract-Detailed Page 9 of 9 DocuSign Envelope ID:34CE7D89-8D6A-4A1B-AD16-36E921B9AAC9 Project Name: Jeffrey Zesiger Today's Date: 6/4/2021 ?if.* Quote#: 14015383 This is a "Do-it-Yourself" project all dimensions, attributes, installation, and disposal are the responsibility of others. Signature: We cannot guarantee that existing window treatments(i.e.Shades, Blinds,and Interior Shutters) will fit on new Pella Windows/Doors. This is an Installed project Condition of Work: 1.50%Deposit required at time of order. 2.Final payment is to be made to installation team on the final day of installation. 3.If the customer will not be present at time of install,payment is to be made prior. 4.Checks returned NSF will be assessed a fee of$50.00 to cover fees incurred by Pella. Failure to pay your final bill will result in finance charges of 1-1/2%per month(18%Annual)and legal fees associated in the collection of owed monies. 5.We cannot guarantee/will not your existing shades and blind will fit in your new windows. 6.Due to inclement weather or site conditions,it may be necessary to reschedule. 7.We cannot and will not guarantee specific dates or days of the week for installation. 8.Time given to complete a job is an estimate,extension of time is possible. 9.An install appointment will be confirmed at Verification.A courtesy reminder call will be placed 3-days prior. 10.Unforeseen rot repair will be quoted on site as additional work via a Field Change Order. Rot repair or additional installation charges are due at the time of installation and cannot be financed through GreenSky Financing,Check or Credit Card Payments only. 11.Upon Substantial Completion final payment is due,Substantial Completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are covered by Warranty and do not affect the status of a project from being Substantially Complete. 12.In the event any products are unable to be installed,the final payment will be recalculated.The cost of the products not installed will be subtracted from the balance due.A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion. 13.Pella will secure all necessary Building Permits. For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella°website at www.pella.com Type of Installation: X New Construction:(tear out installation-existing frame is disposed of) x Remove interior and exterior Trim,remove existing window frame,install new window in rough opening,trim both interior and exterior of window/door. Pocket Install:(sash replacement,existing frame remains) x Remove interior or exterior window stops,install new window in existing sash opening,re-use existing or replace window stops.Some glass loss will occur. Lead Paint Discloser: x Home was built prior to 1978,Pre-Renovation Form signed and"Protecting Your Family From Lead in Your Home" brochure has been given to the Home Owner. _Are there children under the age of 6 or women who are pregnant? DocuSign Envelope ID:34CE7D89-8D6A-4A1 B-AD16-36E921 B9AAC9 fi* Condition of Work(Continued): Owner Will: n Authorize installation of Yard Sign 7-10 days prior to installation date and removed after installation is complete. _Ensure someone over age 18 is present at all times while Pella Employees are in the home Cut-back or tie trees,bushes,shrubs from exterior wall(Grass and Shrubs may be damaged during construction) _Have alarm system disconnected and reconnected-Pella Products can re-route wires but cannot reconnect _Have any plumbing or electrical repairs by appropriate licensed contractor-$500 charge if unprepared on 1-Day job _Remove and reinstall window treatments,wall hangings and A/C Units-4-5 feet in front/1 foot to side with clear path _Remove and reposition furniture in work area DS —Secure pets in a safe manner aluable/breakable items from work area L _Remove snow from area of worksite if necessary Pella Products Will: Deliver and unload products Place drop cloths in work areas _Remove and reinstall interior and exterior trim if applicable Remove and reinstall existing shutters and awnings by contract Remove existing product and adjust or modify opening as needed Provide all equipment necessary to install products _Cut all wood and other materials outside of home Install all products purchased Insulate and caulk around products Remove stickers and perform initial cleaning of all glass surfaces _Demonstrate proper operation of products Ds Confirm that all products are in working order R rop cloths,vacuum and remove all old products from premises nstaller will collect balance due on final day of installation PRE-FINISH DISCLAIMER Stained and paint color samples are produced as accurately as possible: however, actual colors may vary from batch. Because wood is a natural product,each window or door will display its own personality with regards to variation in color,texture and grain pattern. Natural wood variations include distinctive grain patterns or unusual shadings in color. Due to the nature of using natural products, Pella Windows and Doors cannot be responsible for the actual degree of variation that may occur in your purchase. DoeuSigned by: Signature: 9 -' Today's Date: 6/4/2021 `—11 iuUU9i3Ub1 CF4b4... DocuSign Envelope ID:34CE7D89-8D6A-4A1 B-AD16-36E921 B9AAC9 Pella Products Inc. 71* 155 Main Street Greenfield, MA 01301 To Whom it may Concern: I,Jeffrey Zesiger , as property owner, give permission to our contractor, Pella Products Inc.to obtain a building permit for the installation of windows and/or doors in my home. Located at; 2 Pomeroy Ter Apt 7 Northampton, MA 01060 Please accept this letter in place of my signature on the permit application. Thank you, ,-DocuSigned by: 9-"c112----- Signature: `—71 B0098D51 CF454_.. Date: 6/4/2021 DocuSign Envelope ID:34CE7D89-8D6A-4A1 B-AD16-36E921 B9AAC9 PRE-RENOVATION FORM 7A Occupant Confirmation YEAR OF CONSTRUCTION (check one) ACTUAL YEAR HOME CONSTRUCTED 1863 I certify that my home was built BEFORE AFTER Dec. 31, 1977 PRESUMED LEAD X Property Address: 2 Pomeroy Ter Apt 7 Additional Notes: Northampton, MA 01060 If BEFORE is selected,continue to LEAD TESTING APPROVAL. If AFTER is selected,proceed to the PRINT NAME/SIGNATURE section. LEAD TESTING APPROVAL I agree to have Lead Testing performed in my home by Pella Products,Inc. I understand the Lead Testing protocol may cause: Cuts and chips through the existing finish on and around the windows and doors included with this project;including interior and exterior trim,painted walls,and exterior siding. Staining or discoloration of the existing interior and exterior finishes occurring in the tested areas. Interior and exterior trim to be damaged due to removal to provide access for the Lead Testing Protocol. TESTING RESULTS I have reviewed the results of the Lead Testing accomplished by the above named Certified Renovator. I understand the results of my test will be sent to be me,via U.S.mail,within 30 days of the renovation.I have been shown the testing swabs as used for this testing and understand if any test swab indicates a shade of red,lead is assumed present and EPA Renovation,Repair and Painting Guidelines apply. CHECK ONE OF THE FOLLOWING: (A)My home tested positive for lead. I request that Pella Products,Inc use the lead-safe work practices required by the EPA's Renovation,Repair and Painting Rule and will be supplied a pamphlet on lead hazard. (B)My home tested negative for lead. I understand that Pella Products,Inc will not be required to use the lead- safe work practices required by the EPA's Renovation,Repair and Painting Rule and will not be supplied with a pamphlet on lead hazard. PAMPHLET RECEIPT IIF POSITIVE OR PRESUMED LEAD IS PRESENT] X I have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the work began. [Tenant occupied dwellings require a separate notification process.] RENOVATOR'S SELF-CERTIFICATION Jeffrey Zesiger (for tenant-occupied dwellings only) Instructions to Renovator:If the lead hazard information pamphlet was delivered Printed Name of Owner-Occupant but a tenant signature was not obtainable,you may check the appropriate box below: /—DocuSigned by: 9-6CA,,..--------- Declined by tenant;a copy was left with the tenant �. Unavailable for signature;good faith effort made and have left a copy Jlll VitrOwner-Occupant at the residence for the tenant Mailing Option;pamphlet must be mailed at least 7 days before 6/4/2021 renovation and mailing must be documented by a certificate of mailing from the Post Office. Signature Date (This is an alternative to delivery in person to the owner and/or tenant.] PELLA PRODUCTS INC. 155 MAIN STREET GREENFIELD, MA. 01301 Date: — 7 ' a 3 a G To: l 'r 0-c N oc 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 _ The Commonwealth of Massachusetts Department of Industrial Accidents ' T. � Office of Investigations ! Lafayette City Center 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.El I am a employer with 50 4. In I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h' 9. 0 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, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] • *My 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: EMC INSURANCE COMPANIES Policy#or Self-ins. ^Lic. #:6H 15382 Expiration Date:0 1-0 1-2022 oc Job Site Address: 9...)NY\i2_ -T-esA.A_aLk. Ap+ -• City/State/Zip: 11(S(C'irr ti\I t MR- °IOLoO 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 r ler the pains d pal of perju that the information provided above is true and correct. Signature: Date: -7.oD 3 .c . Phone#: 1413 "17 P- 0153 X 317- 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): 11:1Board of Health 2❑Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Eillumbing Inspector 6.0Other Contact Person: Phone#: 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 —1 Division of Professional Licensure Unrestricted -Buildings of any use group which contain Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed >nstructtbrhiUpervisor space. CS-096558 Expires:03i01:2022 TREVOR BROSS r 4 10 GEORGE ST (111).‘ GREENFIELD* • A 'r*fi.1-1C1'� Failure to possess a current edition of the Massachusetts Commissioner State Budding Code is cause for revocation of this license. For information about this license Call(617)7273200 or visit www.mass.goldpl //%O,J4ezei2Cl ie 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 Expiration Office of Consumer Affairs and Business Regulation 142279 03/23/2022 1000 Washington Street -Suite 710 ,• PELLA PRODUCTS,INC. Boston,MA 02118 ELWIN HERRINGSHAW ' r�/` P 155 MAIN STREET GREENFIELD,MA 01301 Undersecretary Not valid without signs e 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 C5065102 Robert Kairnes CS113305 Igor Kravchuk CS094911 PELLPRO-01 CHRISTINE ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM°D YYYY) 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 Phillips Insurance Agency,Inc. PHONE (413)594-:i984 F 413 592-8499 97 Center Street (N No, No►:( Chicopee,MA 01013 Mem christineephillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC I 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.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IMlIt TYPE OF INSURANCE ADDL SUM POLICY NUMBER IWIDDI POLICY EFF POLICY EXP LIs LIR NBD VD YYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I CLAIMS-MADE X OCCUR 6A15382 1/1/2021 1/1/2022 F sEg EeacTEDsnca) $ 500,000 MED EXP(Anyone person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE pLIRM�IT APPLIES PER: GENERAL AGGREGATE '.$ 2,000,000 POLICY X JELT LOC PRODUCTS-COM°/OP AGO $ 2,000,000 OTHER: S A AUTOMOBILE LIABWTY ((EOM a tSINGLE LIMIT $ 1,000,000 X ANY AUTO 6Z15382 1/1/2021 1/1/2022 BODILYINJURY(Perperson) $ OWNED SCHEDULED AUTOS�E�ONLY AUTOS p P BODILY INJURY(Per eminent) $ AUTOS ONLY AUUTNOS ONLY (PRero entDAMAGE S $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESSLUAB CLAIMS-MADE 6J15382 1/112021 1/1/2022 AGGREGATE ; 4,000,000 DED X RETENTIONS 10,000 S B WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVEY/N 6H15382 1/1/2021 1/1/2022 EL EACH ACCIDENT = 500,000 FFICER/MEMBER EXCLUDED? PI Mandatory in NH) EL DISEASE-EA EMPLOYEE$ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2018/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD